Tibial fractures with associated infrapopliteal arterial injuries have been inadequately documented in the literature. Eighteen patients with these injuries were admitted to Boston City Hospital during a 10-year period. Three patients required below-knee amputation, and two of these had ischemic intervals of greater than 8 h before vascular treatment. Six patients had delayed diagnoses of arterial injuries, but none required amputation. There were 15 open and three closed tibial fractures. Nine fractures were badly comminuted. Eight of the 14 viable limbs had delayed unions, but only one was associated with local vascular insufficiency. Five patients had complaints attributed to vascular insufficiency without clinical findings. Our conclusion is that the limb with an infrapopliteal arterial insult combined with a tibial fracture can survive with patency of only the anterior tibial or posterior tibial artery. Poor clinical results correlate with the severity of bony injury and not with the particular arterial injury. The incidence of below-knee amputation can best be related to delay in vascular treatment.