Between 1989 and 1995 a total of 47 patients with 50 fractures of the ipsilateral femoral and tibial shafts without significant articular involvement were treated at Tampa General Hospital. Within this group were 24 patients with 26 fractures who were treated with intramedullary fixation of both bones using a technique of retrograde insertion of a femoral nail and unreamed insertion of an interlocking tibial nail. Information concerning the injuries, treatments, and much of the follow-up was gleaned from a trauma registry. Five of the femoral fractures (19%) and 14 of the tibial fractures (54%) were open. Associated injuries were present in 18 of the 24 patients (75%) with injuries of the pelvis, other extremities, and head being most prevalent. The average Injury Severity Score was 14 (range 9-32). The femoral nails were placed either through the medial femoral condyle (n = 14) or the intercondylar notch of the distal femur (n = 12). Twenty patients with 22 extremities had sufficient follow-up at an average of 20 months (range 4-60) postinjury to be included in the review. One patient had died, and three were completely lost to follow-up. Both fractures in 14 extremities had healed or were healing uneventfully at final review. Seven of the tibiae and three of the femora had complications after initial hospitalization. Two patients developed problems in both bones. Three patients had electrical stimulation of a tibia fracture, one of which underwent simultaneous nail dynamization. A total of 18 additional operative procedures were necessary after the primary treatment in six problematic extremities. Thirteen additional operative procedures were required in five complicated tibiae (one nail dynamization, six debridement procedures, five bone grafts, and one muscle flap) after the initial hospitalization. Five additional operative procedures were required in the three complicated femora (two nail dynamizations, one bone graft, and two exchange nailing procedures). Functional results were good or excellent in 13 of the 20 patients (65%) and 15 of the 22 extremities (68%) available at final review. No significant knee problem related to the femoral nailing technique was identified. This method of treatment can be performed using a standard radiolucent table and a single medial parapatellar incision. It is expedient and allows other procedures to be performed simultaneously in this group of severely injured patients.