The optimal timing of surgical stabilization of fractures in the multitrauma patient is controversial. There are advantages to early definitive surgery for most patients. Early temporary fixation using external fixators, followed by definitive fixation (ie, the damage control approach), may increase the chance for survival in a subset of patients with severe multisystem injuries. Improved understanding of the pathophysiology of trauma has led to a greater ability to identify patients who would benefit from damage control surgery. A patient is classified as physiologically stable, unstable, borderline, or in extremis. The stable patient can undergo fracture surgery as necessary. An unstable patient should be resuscitated and adequately stabilized before receiving definitive orthopaedic care. The decision whether to perform initial temporary or definitive fixation in the borderline patient is individualized based on the clinical condition. In patients presenting in extremis, life-saving measures are pivotal, followed by a damage control approach to their injuries.