Records of 132 consecutive patients with multiple musculoskeletal injuries were examined for the purpose of assessing the relationship between the length of time from injury to the operative stabilization of major fractures and the incidence of adult respiratory distress syndrome (ARDS). To be included in the study patients had to have had at least two major long-bone fractures and a Hospital Trauma Index-Injury Severity Score (ISS) of 18 or higher. Early operative fracture stabilization (STAB) is defined as an operation in the first 24 hours postinjury at which the majority of fractures were stabilized without leaving a spine, pelvis, or femur fracture unstable. A stepwise logistic regression was performed on the data. The dependent variable was the presence or absence of ARDS. The independent variables were age, sex, number of injuries, days to first surgery, early operative fracture stabilization (STAB), units of blood the first week, and ISS and its major components: RESP, ABD, CV, EXT, NS, and SSQ. The two independent variables selected as significant by this procedure were STAB and ISS. For the overall data set, a delay in orthopedic surgery (greater than 24 hours) is associated with a five-fold increase in the incidence of ARDS (p less than 0.001). For the more severely injured patients (ISS greater than 40), the comparable rates are 17% with early surgery and 75% with delayed surgery (p less than 0.001). A Chi-square test for association between ARDS and STAB adjusting for changes due to ISS grouping is significant (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)