Gunshot wounds below the popliteal fossa: A contemporary review

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.