Initial diligent resuscitation of the multiply-injured patient, with early fixation of the major orthopaedic injuries, has significantly reduced the incidence of post-traumatic respiratory complications from the unacceptably high levels which were seen 20 years ago. With these improvements we may be entering an era in which the risk of these complications is independent of the orthopaedic injury and is determined largely by the severity of injury to other body systems or by the immune and physiological status of the patient. Substantive proof of any beneficial effect from modification of the timing and technique of fracture stabilisation will be difficult to achieve without large multicentre randomised trials. It is conceivable that these interventions have a negligible effect on outcome or may actually be detrimental. Unravelling the basic molecular and cellular pathogenic processes of ARDS and FES will lead to improved therapeutic strategies for the treatment of this condition. For the present, however, the evidence suggests that expedient and appropriate early treatment of fractures in most instances protects against the development of post-traumatic respiratory insufficiency. Currently, the best and most effective therapeutic tool of the practising orthopaedic/trauma surgeon is prevention.