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Objectives: To assess the volume and distance traveled for fracture care at a rural trauma center and how this varied over time by case type and by payer., Design: A retrospective review of the electronic record., Setting: A rural level 1 trauma center., Patients/participants: Adults presenting with operative orthopaedic trauma at a rural level 1 trauma center between 1990 and 2007., Intervention: Not applicable., Main Outcome Measurements: County of residence was used to calculate distances traveled to the tertiary care center. Case volume and distance traveled for care were compared by case type, early (1990-1997) and late (1998-2007) time periods, and by payer status. Injury severity score was compared by case type and time period., Results: The presentation of simple injuries to the referral center increased throughout the study period without an increase in injury severity. The percentage of patients with simple injuries covered by standard Medicaid doubled from 11.8% to 21.2% between the early and late time periods. The average distance traveled by patients with simple injuries increased over time from 35.2 to 51 miles, and the distance was greater for Medicaid patients (59.7 vs 42.6 miles). Medicaid patients with emergent injuries also traveled farther for care (77.4 vs 66.1 miles)., Conclusions: Increasing volume of orthopaedic trauma at a rural level 1 trauma center was associated with increasing travel distance for patients. Specifically, there was a dramatic increase in the volume of patients presenting for the care of simple orthopaedic injuries, these patients traveled greater distances with time and were more likely to beon Medicaid. Patients presenting with emergent injuries were also more likely to be on Medicaid. The appropriate triage of orthopaedic injuries requires a well-designed trauma system, including local on-call orthopaedists who can appropriately direct the care of patients with a variety of injuries. The effect of payer status on travel distance may be addressed through changes in reimbursement. Long-distance referral of orthopaedic trauma deserves further study as it affects patient outcomes, cost, and convenience of care.