Ipsilateral femoral neck and shaft fractures are uncommon injuries that present a surgical challenge. Patients are relatively young, are usually victims of high-energy trauma, and have frequently sustained multisystem injuries. A comminuted midshaft femoral fracture secondary to axial loading should alert the treating physician to the possibility of an associated femoral neck fracture. This is important in light of the frequency of unrecognized ipsilateral femoral neck fractures. Several treatment options are described in the literature, but no clear consensus exists regarding the optimal treatment of these complex fractures. The authors contend that, given the potentially devastating complications of the femoral neck fracture in young patients (e.g., avascular necrosis, nonunion, and malunion), the neck fracture should be treated first and the shaft fracture second. The authors present an algorithm for the diagnosis and management of this injury based on a review of the literature, an understanding of the biology and severity of this injury, and the technical aspects of surgical treatment.