Popliteus

tendon
Popliteofibular
ligament
A

C
 Posterior capsule

Semimembranosus Suture
threader
 Sartorius

Medial collateral
ligament

Anteromedial
Incision
capsule

Pes anserinus

Femur Gracilis

Tibia Semitendinosus
 Lax medial
posterior
capsule Lateral

Semimembranosus Tibia
muscle
(tendon omitted)
Direct head

Medial
Posterior capsule

Semimembranosus
muscle

Anterior head
3–4 cm
A Incorrect B Correct
 • ABCs of trauma care
• Tetanus prophylaxis
• Initial local debridement in ED
• Cleanse with povidone and normal saline
• Sterile dressing
• Consider initial dose of cefazolin, 1 g
• Splint unstable fracture

Extremity gunshot injury with high-energy

wound, severe contamination, joint penetration,
unstable fracture requiring surgical stabilization,
or clinically unstable patient with signs and
symptoms of vascular injury?

No Yes

Signs of vascular injury? Signs of vascular injury?

No Yes No Yes

Proximate injury?† Angiography‡ If proximate injury,† Exploration or

intraoperative intraoperative
angiography angiography

Yes No Negative Positive

Duplex Doppler Observe Exploration*

Positive Negative

Angiography Definitive wound and fracture care:
• Local debridement in ED
• Irrigation of wound
• Splint or cast, as fracture dictates
Positive Negative • Ciproflexacin, 750 mg PO bid x 3
days (alternative: cephalexin or
dicloxacillin)
• Closure by secondary intention
Definitive wound and fracture care:
• Irrigation and local debridement
in OR
• Stabilize as fracture pattern
dictates
• Cefazolin, 1 g IV q8h x 48–72 h
• Closure by secondary intention

Exploration*
Discharge home
(if no other injuries)

Definitive wound and fracture care:
• Irrigation and local debridement
in OR
• Stabilize as fracture pattern
dictates
• Cefazolin, 1 g IV q8h x 48–72 h
• Closure by secondary intention
Aggressive irrigation and debridement in OR
• Excise contaminated tissue
• Explore wound tract
• External fixation common (possibly IM nail,
rarely ORIF)
• IV antibiotics as per open-fracture protocols
(type I, II, or III), continue at least 48–72 h,
but also until wounds are clean (up to 1–2
weeks for severe contamination)
• Repeat surgical debridement q48h until
wounds are clean
• Closure by secondary intention (possible
skin graft or flap)
High-energy Low-energy
wound wound
Definitive wound and fracture care:
• Irrigation and local debridement in OR
• Arthroscopy or arthotomy for joint
penetration
• Stabilize as fracture pattern dictates
• Cefazolin, 1 g IV q8h x 48–72 h
• Closure by secondary intention