A high-velocity knee dislocation is a true orthopedic emergency. A high index of suspicion is necessary to identify reduced knee dislocations in multiple trauma patients. Coexisting injuries are common in patients with high-velocity knee dislocations. After an initial assessment, the knee joint should be reduced immediately and splinted. Popliteal artery injury is common in high-velocity dislocations. Arteriograms can be helpful but should not delay operative treatment of obvious arterial injuries. Early restoration of flow to the ischemic limb will avoid amputation in most patients. The orthopedic surgeon must consider a variety of approaches when treating a patient with this type of injury. A spanning external fixator is a useful method for temporary immobilization in knee dislocation patients who have open dislocations, arterial repairs, or closed head injuries. Early surgery to improve the functional stability of the knee must be balanced against the risk of major surgery in patients with severe lower extremity and systemic injuries. The long-term risk of knee stiffness versus instability must be considered. Selective, subacute, aggressive collateral ligament repair and bicruciate reconstruction with allografts offer the best chance for optimal outcome.