Penetrating Ballistic Trauma to the Popliteal Fossa Without Neurovascular Injury Despite High-Risk Trajectory: An Unusual Case Report

Gunshot injuries involving the popliteal fossa are typically considered limb-threatening due to the dense concentration of major vascular and neural structures within the confined anatomical space posterior to the knee joint. Penetrating trauma to this region commonly results in injury to the popliteal artery, popliteal vein, tibial nerve, or common peroneal nerve, often necessitating urgent vascular or reconstructive intervention. Preservation of neurovascular integrity following ballistic trauma to the popliteal fossa is exceptionally uncommon. We report a rare case of an isolated gunshot injury to the popliteal fossa without associated vascular or neurological damage in a 45-year-old male. Clinical examination at presentation demonstrated intact distal perfusion with symmetric pulses, normal ankle-brachial indices (ABI), and preserved motor and sensory function despite the high-risk trajectory of the projectile. Bedside Doppler ultrasound confirmed patent triphasic distal flow. Given the high risk of deep-tract contamination and mechanical joint compromise, immediate emergency surgical exploration, debridement, and bullet removal were performed through a posterior approach with an on-call vascular surgery team on standby. Postoperative computed tomography angiography (CTA) and magnetic resonance imaging (MRI) confirmed absolute neurovascular, ligamentous, and articular integrity, revealing only an isolated posterior femoral cortical defect. This case highlights the importance of meticulous neurovascular assessment and prompt surgical management in penetrating injuries around the knee joint. It also demonstrates that ballistic injuries to the popliteal fossa may rarely occur without compromise of adjacent critical structures despite the anatomical vulnerability of the region. While standard trauma algorithms advocate nonoperative imaging surveillance in stable patients without "hard signs" of vascular injury, immediate surgical exploration remains indicated when macro-contamination or mechanical joint threats are present.