The treatment in such cases is invariably conservative, with the removal of such fragments as may be detached by suppuration and sequestration. [Illustration: Plate 63.] RIFLE--PLATE 63. LOWER EXTREMITY. Gunshot Wound of the Middle of the Tibia, with Few Large Fragments. The course of the bullet was transverse from without inward. The direct impact of the bullet, in high velocity of short range, has produced the typical “X” fracture due to the radiating lines of force. The wound was infected, as is shown by the drainage tubes in the wound. The emergency treatment in such cases is simple antiseptic dressing and temporary splint immobilization. The subsequent treatment is the management of the infection. The results in such cases are favorable. [Illustration: Plate 64.] RIFLE--PLATE 64. LOWER EXTREMITY. Gunshot Fracture of the Tibia. The course of the bullet was diagonal, from without inward and from before backward through the middle of the tibia. Small particles of metal have lodged at the site of the fracture--a condition which never occurs in a rifle wound with the jacket of the bullet intact, while it is the invariable accompaniment of a shrapnel wound of a bone. It is inferred that the jacket of the bullet in this case was damaged by ricochet, or that some metal particles from the object against which the bullet ricocheted were carried into the wound, as some other small pieces of metal are seen in areas distant from the seat of fracture. As the fragments are small and not displaced, the velocity of the missile, at least that of mid-range, was almost sufficient to perforate the bone without fracture. [Illustration: Plate 65.] RIFLE--PLATE 65. LOWER EXTREMITY. Gunshot Fracture of the Tibia. The course of the bullet was transverse, from within outward, striking the bone near the outer border with the velocity of mid or long range, producing long fissures without separation of fragments. The safety pin, of course, lies in the dressings and on the side away from the plate, as shown by its somewhat indefinite outline and increased length. The wounds of entrance and exit are practically the same. The treatment in such cases is that of a simple fracture, except for the management of an occasional infection, and the results are favorable. [Illustration: Plate 66.] RIFLE--PLATE 66. LOWER EXTREMITY. Gunshot Fracture of the Middle of the Tibia, with Lodgment of the Missile. The course of the bullet was transverse, from without inward, striking on the side of the shaft of the tibia. The bullet was so badly damaged by ricochet that only a portion of it was the cause of this wound. The range was short, if not close, as the missile after striking a resisting object with force enough to break itself retained enough energy in a fragment of less than half its mass to cause a long fissure fracture, with the separation of smaller fragments.