Army Medical College Bogura - Orthopaedics SAQ & SEQ Answers

Question 1 — 55-year-old woman, fall on outstretched hand, dinner fork deformity of left wrist

a) Define this injury (1.0)

b) How will you evaluate this patient? (1.5)

• Mechanism - fall on outstretched hand, direction of force
• Dominant hand, occupation, baseline functional status
• Symptoms: pain, swelling, inability to move wrist

• Inspection: dinner fork deformity, swelling, bruising
• Palpation: tenderness over distal radius within 2 cm of radial articular surface, radial shortening, crepitus
• Neurovascular status: median nerve (most commonly injured - check thumb opposition, sensation over palm/index/middle fingers), radial and ulnar nerves, capillary refill, radial pulse
• Associated injuries: elbow, shoulder

• X-ray wrist - PA and lateral views
  • PA: radial shortening, intra-articular extension into radiocarpal or radioulnar joints, ulnar styloid fracture
  • Lateral: dorsal displacement, dorsal angulation, loss of normal volar tilt of distal radial articular surface (normal volar tilt ~11°)
• CT scan if intra-articular comminution needs further delineation

c) Why are old women more prone to this injury? (1.0)

1. Osteoporosis - Post-menopausal women have markedly reduced estrogen, leading to accelerated bone resorption and reduced bone mineral density. The distal radius (a cancellous-rich area) becomes particularly weak.
2. Increased fall risk - Elderly women have impaired balance, muscle weakness (sarcopenia), visual impairment, and orthostatic hypotension.
3. Protective response - On falling, they instinctively outstretched their hand, directing force through the weak distal radius.
4. Body habitus - Reduced muscle mass in older women means less energy absorption before force reaches bone.

Question 2 — Middle-aged female, fall on outstretched hand, swelling of right forearm just above wrist

a) Enumerate injuries caused by fall on outstretched hand (FOOSH) (1.0)

1. Colles' fracture - distal radial metaphysis, dorsal displacement
2. Smith's fracture - distal radius, volar displacement (reverse Colles')
3. Scaphoid fracture - most common carpal fracture; tenderness in anatomical snuffbox
4. Barton's fracture - intra-articular fracture-dislocation of distal radius (dorsal or volar)
5. Chauffeur's (Hutchinson's) fracture - radial styloid fracture
6. Distal radius fracture (in children: greenstick/torus fractures)
7. Monteggia fracture-dislocation - proximal ulnar fracture + radial head dislocation
8. Supracondylar fracture of humerus (especially in children)
9. Dislocation of shoulder or elbow
10. Fracture of neck of radius

b) Radiological findings expected (1.0)

• PA view: Fracture line within 2 cm of distal radial articular surface; radial shortening; loss of radial inclination (normally ~22°); possible ulnar styloid fracture; intra-articular extension
• Lateral view: Dorsal displacement and angulation of distal fragment; loss of volar tilt (normally ~11°) - may show neutral or dorsal tilt; classic "dinner fork" profile on lateral

c) Early and late complications (1.5)

• Median nerve injury - most common nerve injury (acute contusion, traction, compression)
• Radial/ulnar nerve injury
• Vascular injury (radial artery)
• Acute carpal tunnel syndrome
• Compartment syndrome (rare)
• Associated soft tissue injuries

• Malunion - most common; results in radial shortening, loss of volar tilt, wrist deformity, weakness
• Post-traumatic osteoarthritis - especially with intra-articular fractures
• Sudeck's atrophy (Complex Regional Pain Syndrome / CRPS Type I) - pain, stiffness, vasomotor instability, osteoporosis
• Carpal tunnel syndrome - chronic median nerve compression
• Rupture of extensor pollicis longus tendon - attrition rupture over Lister's tubercle
• Stiffness of wrist and finger joints
• Secondary shoulder stiffness (from prolonged immobilization)
• Avascular necrosis of scaphoid (if associated scaphoid fracture missed)

Question 3 — 10-year-old boy, FOOSH, pain and swelling of right elbow

a) Probable diagnosis (0.5)

b) Management (1.5)

• Neurovascular status is MANDATORY - check radial pulse, anterior interosseous nerve (AIN: tip-to-tip pinch of thumb and index finger), radial nerve (wrist extension), median nerve, ulnar nerve
• Immobilize in a posterior splint (not in full flexion if swollen)

• Most displaced fractures: closed manipulation under general anesthesia + percutaneous K-wire fixation (two lateral entry wires or crossed wires)
• Above-elbow cast for 3-4 weeks post-fixation
• White pulseless hand = surgical emergency: immediate reduction; if pulse doesn't return, vascular exploration by trained surgeon
• Pink pulseless hand = close monitoring; if satisfactory perfusion, reduce and stabilize first

c) Probable complications (1.5)

• Neurovascular injury (anterior interosseous nerve most common; radial, median, ulnar nerves)
• Vascular injury - brachial artery injury (white pulseless hand)

• Volkmann's ischaemic contracture - most feared complication; due to compartment syndrome from excessive swelling or positioning in deep flexion; results in fibrosis and contracture of forearm flexors
• Compartment syndrome
• Malreduction

• Cubitus varus ("gunstock deformity") - most common late deformity; due to malunion with medial rotation/varus angulation; mainly cosmetic but may require corrective osteotomy
• Cubitus valgus - less common
• Elbow stiffness/loss of movement
• Myositis ossificans - especially if passive stretching done early
• Avascular necrosis of trochlea (rare)
• Tardy ulnar nerve palsy (with cubitus valgus)

Question 4 — 55-year-old lady, FOOSH, painful swelling and dinner fork deformity of wrist

a) Most likely diagnosis and reverse type (1.0)

• Transverse fracture of distal radial metaphysis within 2 cm of articular surface
• Dorsal displacement and angulation → dinner fork deformity

• Fracture of distal radius with volar (anterior) displacement and angulation of the distal fragment
• Mechanism: fall on a flexed wrist or direct blow to dorsum of wrist
• Produces a "garden spade" deformity (volar prominence)

b) Investigation (1.0)

• PA: fracture at distal radial metaphysis, radial shortening, possible ulnar styloid fracture, intra-articular extension
• Lateral: dorsal displacement and dorsal angulation, loss of volar tilt (normal ~11°)

• CT scan: if significant intra-articular comminution or complex pattern
• Bone density scan (DEXA): post-fracture to assess for osteoporosis
• Bloods: baseline before any intervention

c) Treatment (1.5)

1. Closed reduction under procedural sedation / hematoma block / Bier block / regional nerve block
   • Restore radial length, correct dorsal angulation (especially >20°), restore volar tilt
   • Techniques: traction-countertraction, Cotton-Loader position
2. Immobilization: Double sugar-tong splint (acute) → below-elbow cast for 4-6 weeks
   • Wrist in slight volar flexion and ulnar deviation
   • Avoid circumferential cast in first 24-48 hours (edema risk)
3. Urgent orthopedic referral within 2-3 days

• Significant comminution, displacement, or intra-articular step-off >2 mm
• Failure to maintain reduction
• Neurovascular compromise
• Open fractures
• Highly displaced or unstable fractures in active patients

• Percutaneous K-wire fixation
• Volar locking plate (ORIF) - current standard for unstable/displaced fractures
• External fixation (for severely comminuted fractures)

Question 5 — Monteggia/Galeazzi, Clavicle fracture

a) Define Monteggia and Galeazzi fracture dislocations (1.0)

• Fracture of the proximal third of the ulna + dislocation of the radial head
• Bado classification (Types I-IV) based on direction of radial head dislocation
• Type I (most common): fracture of proximal ulna with anterior dislocation of radial head
• Radiocapitellar line (drawn along radial shaft) should pass through center of capitellum - disruption indicates radial head dislocation

• Fracture of the distal third of the radius + disruption of the distal radioulnar joint (DRUJ)
• Called the "fracture of necessity" because it almost always requires operative fixation
• Opposite to Monteggia in pattern

b) Outline management of clavicle fracture (1.5)

• Middle third (most common, 70-80%)
• Lateral/distal third (15-20%)
• Medial third (rare, 5%)

• Neurovascular exam (subclavian vessels, brachial plexus)
• Check for associated pneumothorax, rib fractures
• AP X-ray of clavicle (cephalic tilt views for better visualization)
• CT for medial fractures/physeal separations

• Arm sling for 4-6 weeks for comfort (simple broad arm sling)
• Figure-of-eight bandage: NOT currently recommended (increased complications, brachial plexus palsy risk with prolonged use)
• Analgesics, physiotherapy after pain resolves
• Most fractures unite without complication

• Absolute: open fracture, neurovascular compromise, floating shoulder (associated scapular fracture), severe skin tenting
• Relative: shortening >2 cm, significant displacement/comminution, nonunion, high-level athlete, bilateral clavicle fractures

• Open reduction and internal fixation (ORIF) with plate and screws (superior/anterior plating)
• Intramedullary nailing

c) Structures that may be injured due to clavicle fracture (1.0)

1. Subclavian artery and vein - may be lacerated by sharp fracture fragments; especially with proximal/medial fractures
2. Brachial plexus (trunks of C5-T1) - traction or direct injury; neurological deficit in arm
3. Lung apex and pleura - pneumothorax or haemothorax (especially with displaced proximal fractures)
4. Subclavian/axillary vein - venous injury, thrombosis
5. Trachea and oesophagus - especially with posterior sternoclavicular dislocation/medial fractures
6. Thoracic duct - rarely, on the left side
7. Acromioclavicular and sternoclavicular joints - ligamentous injury

Question 6 — 65-year-old lady, pain and swelling around hip, inability to walk, fall 3 days ago

a) Two differential diagnoses (0.5)

1. Fracture of the neck of femur (Femoral neck fracture / Intracapsular hip fracture)
2. Intertrochanteric fracture (Extracapsular hip fracture)

b) How will you diagnose? (1.5)

• Fall mechanism, site of pain (groin, hip, thigh)
• Inability to weight-bear
• Pre-injury mobility and functional status

• Attitude of leg: shortened, externally rotated (displaced femoral neck / intertrochanteric fracture)
• Tenderness over hip region (greater trochanter for intertrochanteric; groin for intracapsular)
• Inability to perform straight leg raise (Pons/heel-to-floor rise sign)
• Neurovascular assessment

• X-ray pelvis (AP) and lateral hip - first line; identifies most fractures
  • Fracture line location, displacement, Garden classification (for intracapsular)
  • Trabecular pattern disruption in subtle fractures
• MRI hip - most sensitive for occult fractures (missed on plain X-ray in ~15% of cases); investigation of choice if clinical suspicion high and X-ray negative
• CT - useful if MRI unavailable, for operative planning in complex fractures
• Bloods: FBC, renal/liver function, clotting, group & screen (pre-operative)
• ECG, chest X-ray (pre-operative fitness)

c) Treatment (1.5)

• Optimize medical comorbidities rapidly; aim for surgery within 48 hours
• DVT prophylaxis (LMWH), pressure sore prevention, adequate analgesia

• Dynamic Hip Screw (DHS) and plate fixation - standard treatment
• Intramedullary nail (cephalomedullary nail) for unstable/subtrochanteric patterns
• Blood supply at less risk, so avascular necrosis uncommon

• Medically unfit for surgery: skin traction, bed rest, early mobilization as tolerated
• Risk of malunion, non-union, pressure sores - generally avoided unless no surgical option

• Early mobilization (day 1 post-op if possible)
• Physiotherapy, occupational therapy
• Osteoporosis treatment (bisphosphonates, calcium/vitamin D) to prevent future fractures
• Falls prevention assessment

• Colles' = dorsal displacement; Smith's = volar displacement (reverse Colles')
• Monteggia = proximal ulna + radial head dislocation; Galeazzi = distal radius + DRUJ disruption
• Supracondylar fracture in children: most feared complication = Volkmann's ischaemic contracture; most common late deformity = cubitus varus
• Clavicle fracture: arm sling preferred over figure-of-eight; beware subclavian vessels, brachial plexus, pneumothorax
• Hip fractures in elderly: displaced intracapsular → hemiarthroplasty/THR; extracapsular → DHS

Army Medical College Bogura — Orthopaedics Ward Assessment Exam (SAQ & SEQ)

Question 1 — 55-year-old woman, FOOSH, dinner fork deformity of left wrist

a) Define this injury (1.0)

• Mechanism: Fall On OutStretched Hand (FOOSH) with wrist in dorsiflexion
• The dorsal displacement of the distal fragment creates the characteristic "dinner fork deformity" on lateral view

b) How will you evaluate this patient? (1.5)

• Mechanism of injury (FOOSH), dominant hand, occupation
• Pain, swelling, deformity, inability to move wrist
• Comorbidities (osteoporosis, previous fractures)

• Inspection: Dinner fork deformity, swelling, bruising, skin integrity
• Palpation: Tenderness over distal radius, radial shortening, crepitus, ulnar styloid tenderness
• Neurovascular assessment (mandatory):
  • Median nerve (most commonly injured): thumb opposition, sensation over thumb/index/middle fingers and radial palm
  • Radial and ulnar nerve function
  • Radial pulse, capillary refill
• Range of movement (limited by pain)
• Examine elbow and shoulder for associated injuries

• X-ray wrist — PA and lateral views:
  • PA: fracture within 2 cm of articular surface, radial shortening, loss of radial inclination (~22° normally), ulnar styloid fracture, intra-articular extension
  • Lateral: dorsal displacement and angulation, loss of volar tilt (normal ~11°) — the "dinner fork" profile
• CT scan if significant intra-articular comminution needs further evaluation

c) Why are old women more prone to this injury? (1.0)

1. Osteoporosis — Post-menopausal estrogen deficiency leads to accelerated bone resorption and reduced bone mineral density; the cancellous-rich distal radius is particularly vulnerable
2. Increased fall risk — Elderly women have impaired balance, muscle weakness (sarcopenia), poor vision, and orthostatic hypotension
3. Protective reflex — On falling, they instinctively oustretch the hand, directing the full force through the weakened distal radius
4. Reduced muscle mass — Less energy absorbed by soft tissue before force reaches bone

Colles' fracture is considered a sentinel fragility fracture and should prompt investigation and treatment for osteoporosis.

Question 2 — Middle-aged female, FOOSH, swelling of right forearm just above wrist

a) Enumerate injuries caused by fall on outstretched hand (1.0)

1. Colles' fracture — distal radial metaphysis, dorsal displacement
2. Smith's fracture — distal radius, volar displacement (reverse Colles')
3. Scaphoid fracture — most common carpal fracture; anatomical snuffbox tenderness
4. Barton's fracture — intra-articular fracture-dislocation of distal radius
5. Chauffeur's (Hutchinson's) fracture — radial styloid fracture
6. Distal radius fractures in children — greenstick, torus/buckle fractures
7. Monteggia fracture-dislocation — proximal ulna fracture + radial head dislocation
8. Supracondylar fracture of humerus — especially in children
9. Dislocation of elbow or shoulder
10. Fracture of neck of radius

b) Radiological findings expected (1.0)

• PA view:
  • Transverse fracture within 2 cm of distal radial articular surface
  • Radial shortening
  • Loss of radial inclination (normal ~22°)
  • Fracture of ulnar styloid process (common association)
  • Possible intra-articular extension into radiocarpal or radioulnar joints
• Lateral view:
  • Dorsal displacement of distal fragment
  • Dorsal angulation — loss of volar tilt (normal ~11°; may become neutral or dorsally tilted)
  • Classic "dinner fork" silhouette

c) Early and late complications (1.5)

• Median nerve injury — most common (contusion, traction, or compression); acute carpal tunnel syndrome
• Radial/ulnar nerve injury
• Brachial artery/radial artery injury
• Compartment syndrome (rare but serious)
• Associated tendon/ligament injuries

• Malunion — most common; radial shortening, loss of volar tilt → weak grip, pain, deformity
• Sudeck's atrophy (CRPS Type I) — pain, swelling, skin changes, stiffness, osteoporosis of hand
• Carpal tunnel syndrome — chronic median nerve compression
• Rupture of extensor pollicis longus (EPL) tendon — attrition rupture at Lister's tubercle (presents weeks later as loss of thumb extension)
• Post-traumatic osteoarthritis — especially with intra-articular extension
• Stiffness of wrist and finger joints
• Secondary shoulder stiffness — from prolonged immobilization
• Non-union (rare for distal radius)

Question 3 — 10-year-old boy, FOOSH, pain and swelling of right elbow

a) Probable diagnosis (0.5)

• Most common elbow fracture in children (peak age 5–10 years)
• FOOSH with elbow in extension forces the distal humerus posteriorly
• Extension type (Gartland classification) accounts for >95% of cases

b) Management (1.5)

• Neurovascular status is mandatory before any intervention:
  • Anterior interosseous nerve (AIN): tip-to-tip pinch of thumb and index finger
  • Radial nerve: wrist/finger extension
  • Median nerve: wrist flexion, thumb opposition, sensation
  • Radial pulse, capillary refill, skin color/warmth

• White pulseless hand = surgical emergency: immediate reduction; if pulse does not return → vascular exploration
• Pink pulseless hand = careful monitoring; if satisfactory perfusion, reduce and stabilize, reassess pulse
• Do NOT put elbow in deep flexion if significant swelling (risk of compartment syndrome/Volkmann's)
• Remove K-wires at 3–4 weeks; progressive mobilization thereafter

c) Probable complications (1.5)

• Anterior interosseous nerve (AIN) injury — most common nerve injury
• Radial, median, or ulnar nerve injury
• Brachial artery injury → vascular compromise

• Volkmann's ischaemic contracture — most feared complication; due to compartment syndrome from swelling or excessive elbow flexion; leads to fibrosis and fixed flexion contracture of forearm flexors
• Compartment syndrome
• Pin-tract infection (if K-wires used)

• Cubitus varus ("gunstock deformity") — most common late complication; malunion with medial rotation/varus tilt; mainly cosmetic but may require corrective supracondylar osteotomy
• Cubitus valgus (less common)
• Myositis ossificans — if aggressive passive manipulation done early
• Elbow stiffness/reduced range of movement
• Avascular necrosis of trochlea (rare — "fishtail deformity")
• Tardy ulnar nerve palsy (with cubitus valgus)

Question 4 — 55-year-old lady, FOOSH, painful swelling and dinner fork deformity

a) Most likely diagnosis and reverse type (1.0)

• Fracture of distal radial metaphysis within 2 cm of articular surface
• Dorsal displacement and angulation → dinner fork deformity

• Fracture of distal radius with volar (anterior) displacement and angulation of distal fragment
• Mechanism: fall on a flexed wrist, or direct blow to dorsum of wrist
• Produces a "garden spade" deformity (ventral prominence)
• Also called "reverse dinner fork" deformity

b) Investigations (1.0)

• X-ray wrist — PA and lateral views (as detailed in Q1b above)
  • Confirms fracture, assesses displacement, angulation, intra-articular extension, ulnar styloid
• CT scan if complex intra-articular comminution needs delineation for surgical planning
• DEXA scan — after acute management, to assess for underlying osteoporosis
• Baseline bloods if operative management planned (FBC, U&E, clotting, group & save)

c) Treatment (1.5)

1. Closed reduction under anesthesia (hematoma block / Bier block / regional nerve block / procedural sedation)
   • Goals: restore radial length, correct dorsal angulation (especially >20°), restore volar tilt
   • Technique: longitudinal traction, then palmar flexion and ulnar deviation
2. Immobilization:
   • Acute: double sugar-tong splint (avoids circumferential cast in first 24–48 hours due to swelling)
   • After swelling subsides: below-elbow cast for 4–6 weeks (wrist in slight volar flexion and ulnar deviation)
3. Repeat X-ray at 1 week to check for re-displacement
4. Urgent orthopedic outpatient review within 2–3 days

• Intra-articular step-off >2 mm
• Radial shortening >5 mm
• Dorsal angulation >20° (or failure to maintain reduction)
• Open fractures
• Associated neurovascular compromise
• Highly comminuted/unstable fractures in active patients

• Volar locking plate (ORIF) — current gold standard for unstable/displaced fractures
• Percutaneous K-wire fixation — simpler, for reducible but unstable fractures
• External fixation — for severely comminuted fractures

Question 5 — Monteggia/Galeazzi, Clavicle fracture

a) Monteggia and Galeazzi fracture-dislocations (1.0)

• Fracture of the proximal third of the ulna combined with dislocation of the radial head
• Bado classification (I–IV) based on direction of radial head dislocation:
  • Type I (most common, ~60%): anterior dislocation of radial head + anterior angulation of ulnar fracture
  • Type II: posterior dislocation of radial head
  • Type III: lateral dislocation
  • Type IV: fracture of both bones + anterior radial head dislocation
• Key radiological sign: radiocapitellar line (drawn along radial shaft) should pass through center of capitellum — disruption indicates radial head dislocation
• Risk: posterior interosseous nerve (PIN) injury

• Fracture of the distal third of the radius combined with disruption of the distal radioulnar joint (DRUJ)
• Called "fracture of necessity" — almost always requires operative fixation (ORIF)
• Risk: ulnar nerve and DRUJ ligament injury

b) Outline management of clavicle fracture (1.5)

• Middle third: 70–80% (most common)
• Lateral/distal third: 15–20%
• Medial third: ~5% (rare)

• Neurovascular examination: brachial plexus, subclavian vessels
• Check for pneumothorax (especially with displaced fractures)
• X-ray: AP clavicle (cephalic tilt views give best visualization); CT for medial fractures

• Broad arm sling for 4–6 weeks — for comfort and support
• Figure-of-eight bandage: NOT recommended (increased complications, risk of brachial plexus palsy)
• Analgesics (NSAIDs, paracetamol)
• Physiotherapy after pain settles
• Most middle-third fractures unite uneventfully

• ORIF with plate and screws (superior or anteroinferior plating) — most common
• Intramedullary nailing — alternative, smaller scar

c) Structures that may be injured due to clavicle fracture (1.0)

1. Subclavian artery — laceration by sharp fracture ends → hemorrhage, false aneurysm
2. Subclavian/axillary vein — venous injury, thrombosis
3. Brachial plexus (C5–T1 trunks) — traction or direct injury → weakness/sensory loss in arm
4. Lung apex and pleura — pneumothorax or haemothorax (especially displaced proximal fractures)
5. Trachea and oesophagus — risk with posterior sternoclavicular dislocation or medial fractures
6. Thoracic duct — rarely (left side only)
7. Acromioclavicular and sternoclavicular joints — associated ligamentous injury

Question 6 — 65-year-old lady, hip pain and swelling, unable to walk, 3-day-old fall

a) Two differential diagnoses (0.5)

1. Fracture of the neck of femur (intracapsular hip fracture)
2. Intertrochanteric fracture (extracapsular hip fracture)

b) How will you diagnose? (1.5)

• Mechanism: low-energy fall (slippery bathroom)
• Site of pain: groin (intracapsular) vs. lateral hip/greater trochanter (extracapsular)
• Inability to weight-bear since fall (3 days ago)
• Pre-injury mobility, functional level, and comorbidities

• Attitude of leg: shortened and externally rotated (displaced fracture)
• Groin tenderness (intracapsular) vs. greater trochanteric tenderness (extracapsular)
• Inability to perform straight leg raise
• Longitudinal pressure/heel strike tenderness
• Neurovascular assessment of lower limb

• X-ray pelvis (AP) + lateral hip — first-line; identifies most fractures
  • Assess fracture location and displacement
  • Garden classification for intracapsular fractures: I (incomplete/valgus impacted), II (complete undisplaced), III (partial displacement), IV (complete displacement)
  • Disruption of trabecular lines indicates subtle fracture
• MRI hip — most sensitive; investigation of choice for occult fractures (missed on plain X-ray in ~15%)
• CT — if MRI unavailable; also useful for operative planning
• Bloods: FBC, U&E, LFTs, clotting, group & screen, blood glucose, ECG, CXR (pre-operative work-up)

c) Treatment (1.5)

• Optimize medical comorbidities urgently
• Aim for surgery within 48 hours (reduces mortality and complications)
• DVT prophylaxis (LMWH), pressure area care, analgesia (nerve block useful), catheter if needed

• Dynamic Hip Screw (DHS) + plate — standard for stable intertrochanteric fractures
• Cephalomedullary nail (e.g., PFNA) — for unstable or subtrochanteric patterns
• Blood supply to femoral head not at risk → fixation favored over replacement

• Skin traction, bed rest, early mobilization
• High risk of malunion, non-union, pressure sores — generally a last resort

• Early mobilization: weight-bear as tolerated from day 1 (hemiarthroplasty)
• Physiotherapy and occupational therapy
• Treat underlying osteoporosis: bisphosphonates, calcium + vitamin D
• Falls prevention assessment and home modification
• Thromboprophylaxis for 28–35 days post-surgery

Sources: Rosen's Emergency Medicine, Bailey & Love's Short Practice of Surgery 28th Ed, Grainger & Allison's Diagnostic Radiology, Campbell's Operative Orthopaedics 15th Ed, Miller's Review of Orthopaedics 9th Ed