In these cases with lateral separation of fragments, it is imperative to supplement extension with pressure in a line perpendicular to the long axis of the femur. [Illustration: Plate 53.] RIFLE--PLATE 53. UPPER EXTREMITY. Gunshot Fracture of the Shaft of the Femur with Lodgment of the Bullet. The course of the bullet was antero-posterior and diagonally inward from the antero-external border of upper third of the thigh. A thin longitudinal fragment was split off without transverse fracture. The missile struck the thigh after its energy had been greatly reduced by ricocheting as a result of striking a resisting object which flattened its nose and “set up” its body, as shown by the wavy outlines of the shadows. The dense and normal-size shadow shows the bullet to be near the plate and probably in the muscles superficially behind and below the lesser trochanter. As the prominent outline of the lesser trochanter shows that the leg was in external rotation when the negative was made, it is evident that, with the rotation back to the anatomical position, the projection of the shadow of the bullet would fall close to or in line with the shaft of the femur; the position of the bullet is behind the femur. The treatment is conservative, with no trouble to be expected from infection. [Illustration: Plate 54.] RIFLE--PLATE 54. LOWER EXTREMITY. Gunshot Fracture of the Lower End of the Shaft of the Femur. The course of the bullet was anteroposterior through the axis of the femur. Several large fragments which were not displaced were separated by the force of impact. The separation of the fragments and the overriding of the ends of the proximal and distal large fragments were due to bearing bodily weight or to muscular contraction. The projectile causing the wound was moving with the velocity of mid range. The wound of exit was not lacerated. The emergency treatment is antiseptic dressing and temporary splint immobilization. Permanent dressing, with extension and lateral compression, is the rule. Infection in such cases is frequent owing to lack of facilities for proper dressing on the field. Results in saving life and limb are generally good. [Illustration: Plate 55.] RIFLE--PLATE 55. LOWER EXTREMITY. Gunshot Fracture of the Lower Third of the Shaft of the Femur. The course of the bullet was diagonally anteroposterior, with a velocity near mid range, without causing much displacement of fragments. The wound of entrance and exit would be almost the same in appearance. Treatment and results would be similar to case shown on plate 54. Many of these wounds are infected, due, no doubt, to the difficulties of arranging a clean first-aid dressing and effecting satisfactory immobilization during the first stage of transportation. Infection from clothing carried into the wound is rare, as the fairly high velocity of the bullet causes a spreading of the fibers without division or punched-out section before the bullet.