The bullet in transverse course and high velocity through both bones of the forearm struck the head of the radius, thus starting several splitting lines of fracture and separating large fragments. Smaller fragments which received some of the energy of the missile have been carried along with it in turn, striking the ulna and carrying away smaller fragments from it and causing the laceration which marks the wound of exit. Such wounds, with laceration of soft parts and fragmentation of the bone, are prone to infection, against which treatment is directed. The indications to be met are much like those of the wound shown in plates 18 and 19. Excision or immediate methods of bone repair are contraindicated by infection. Results will depend upon the nature and extent of infection. [Illustration: Plate 18.] RIFLE--PLATE 18. UPPER EXTREMITY. Gunshot Fracture of the Elbow, without Injury to the Great Vessels and Nerves. Wound of entrance, posterior to the external condyle. Wound of exit, large laceration in front and above the internal condyle. The wound is an example of the misnamed “explosive” action of a rifle bullet. The force and direction of the missile, in high velocity, split the bone into many fragments, and, transmitting its energy to some of the fragments, carried them through the skin and caused the large laceration at the point of exit by the simultaneous escape of the bullet and fragments. The wound was so heavily infected, that a cellulitis advanced to the shoulder and to the wrist to such extent that the arm was marked by eminent surgical opinion for amputation. Free incision, drainage, antisepsis and incidental removal of detached fragments controlled the infection and brought about slow resolution. After six months of careful treatment the wound was healed with an ankylosed elbow with normal function of the forearm, except for limited rotation. Treatment indicated in such cases is always conservative. Infections contraindicate any formal surgical interference. The dangers of infection in such cases are to be risked to avoid amputation. Results may be considered favorable even with elbow ankylosis. [Illustration: Plate 19.] RIFLE--PLATE 19. UPPER EXTREMITY. Gunshot Fracture of the Elbow, without Injury to the Great Vessels and Nerves. This is a plate made of the same subject shown in plate 18, when convalescence was several weeks farther advanced, as is indicated by the removal of fragments and extensive callus formation. Both radiographs were made after the apprehension of systemic infection had passed; the second plate after an additional number of fragments had been removed. [Illustration: Plate 20.] RIFLE--PLATE 20. UPPER EXTREMITY. Gunshot Fracture of the Elbow. Wound of entrance, posterior aspect of forearm internal to and below the olecranon. Wound of exit, external border over head of radius.