The emergency and subsequent treatment is conventionally conservative, as in the preceding cases. [Illustration: Plate 41.] RIFLE--PLATE 41. UPPER EXTREMITY. Gunshot Fracture of the Wrist. Wound of entrance, posterior aspect of forearm over the lower end of the radius, with the bullet ranging forward and slightly downward to the wound of exit and covering with great laceration the anterior aspect of the wrist joint. The range was close, and the energy of the high velocity of the missile was imparted to fragments, which, becoming “secondary missiles,” emerged with the projectile to cause extensive laceration and destruction of tissue. The case was received for amputation in the second week, when a grave degree of infection extended in a cellulitis to the elbow. The ulnar nerve and vessels were intact, but the flexor tendons were almost entirely destroyed. The plate, made after several weeks, when infection was under control and after the end of the radius and fragments of the carpus had been informally removed, shows a rarefaction of the carpus and proximal ends of the metacarpus, due to infection and disuse. Frequent incisions and extension of drainage, with removal of detached fragments, was continued for several months. The wound was closed in the sixth month, with ankylosis and deformity of the wrist, as shown in plate 42. [Illustration: Plate 42.] RIFLE--PLATE 42. UPPER EXTREMITY. Gunshot Fracture of the Wrist. This plate, presenting a lateral view of the wound shown in plate 41, shows considerable deformity of the joint, after four months’ treatment, which was even more marked two months later, when the case was discharged with an ankylosis of the wrist joint, contracture of the flexor tendons of the fingers, and slight flexor function of the thumb, permitting apposition with the first finger. The result, while leaving much to be desired, preserved a function of the hand vastly superior to that of a forearm stump. The treatment in such cases is always courageously conservative, with amputation only as the extreme measure to save life, with risks of judgment in favor of conservatism. Corrective measures may be employed after management if the treatment of the infection is successful and when the case passes out of the military category. It is not possible, during a long infection, to maintain better position in such cases. [Illustration: Plate 43.] RIFLE--PLATE 43. UPPER EXTREMITY. Gunshot Fracture of the Metacarpus. Wound of entrance, inner aspect of the hand over proximal end of the fifth metacarpal. Wound of exit, on the outer border of the hand over the distal end of the second metacarpal. The velocity of the bullet was in mid or long range, as it displaced no fragments, and as it made a point of entrance and exit about the same in appearance. The wound was infected, which is more frequently the case in the hand than in the forearm.