The management of extremity injuries above the knee has been well described
, but the evaluation and treatment guidelines for penetrating injuries belo
w the popliteal crease has received less attention. A 6-year retrospective
review of 100 patients who sustained isolated below-knee gunshot wounds. Pa
tients with proximal extremity, torso, or head wounds were excluded from re
view so that we could focus on principles of managing below-knee wounds. Al
l patients were evaluated with complete physical examination, ankle-brachia
l index, and plain X-rays. One patient presented with hemodynamic instabili
ty. Twenty-four patients underwent arteriography based on physical examinat
ion, an ankle-brachial index less than 0.9, or both. Twenty-two vascular in
juries were identified in 19 patients, and an additional injury was found i
n a patient who went directly to surgery for pulsatile bleeding. Six of the
se 22 vascular injuries required treatment for bleeding or arteriovenous fi
stula. Treatment was by embolization in 5 and surgical ligation in 1. Thirt
een patients had compartment syndromes. Thirty-five patients had fractures,
and ten (29%) of these had an associated vascular injury. Four patients ha
d peroneal nerve injuries, and three of these had long term disability. No
limb loss or death occurred. We conclude that patients with low-velocity be
low-knee gunshot wounds sustain fractures, vascular injuries, compartment s
yndromes, and nerve injuries, in decreasing order of frequency. Arteriograp
hy and embolization may be useful to control bleeding; vascular reconstruct
ion was unnecessary in our experience, and limb loss did not occur.