To assess ballistic femoral shaft fracture outcomes in comparison with closed and open femoral shaft fractures sustained by blunt mechanisms. We hypothesized that ballistic femoral shaft fractures would have similar outcomes to blunt open fractures. Retrospective cohort study. Academic Level I trauma center. Patients 16 years and older presenting with ballistic (140), blunt closed (317), or blunt open (71) femoral shaft fractures. Unplanned return to operating room, fracture-related infection, soft tissue reconstruction, nonunion, implant failure, length of stay, Injury Severity Scores, hospital charges, and compartment syndrome. A total of 528 femoral shaft fractures were identified. A group of 140 ballistic fractures and comparison groups of all femoral shaft fractures sustained by blunt mechanisms and treated with intramedullary nailing were included in the analysis. Among the 2 subgroups of nonballistic injuries, 317 were blunt closed fractures and 71 were blunt open fractures. The ballistic group was associated with a 3-fold increase in overall complications (30%) compared with the blunt closed group (10%, P < 0.001), had a higher occurrence of thigh compartment syndrome (P < 0.001), and required more soft tissue reconstruction (P < 0.001) than either of the blunt fracture groups. Ballistic femoral shaft fractures do not perfectly fit with blunt closed or open femoral fractures. A high index of suspicion for the development of thigh compartment syndrome should be maintained in ballistic femoral shaft fractures. The overall rates of nonunion and infection were comparable between all groups, but the all-cause complication rate was significantly higher in the ballistic group compared with the blunt closed group. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.