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The effect of spastic cerebral palsy on in vivo gastrocnemius muscle fascicle length is not clear. Similarity of fascicle lengths in children with diplegia and typically developing children, but shortening of fascicle lengths in the paretic legs of children with hemiplegia compared with the non-paretic legs, are both reported. In the former case, comparisons were made between fascicle lengths normalized to leg length, whereas in the latter case, absolute fascicle lengths were compared. The inherent assumptions when normalizing fascicle length (measured via ultrasonography) were not validated, raising the possibility that inappropriate normalization contributed to the controversy. We used statistical methods to control the potential confounding effect of leg length on fascicle length, and tested the feasibility of the normalization method for a group of 18 children with diplegia (nine males, nine females; mean age 8y 7mo [SD 3y 11mo], range 2-15y; Gross Motor Function Classification System levels II and III) and 50 typically developing children (20 males, 30 females; mean age 9y 1mo [SD 2y 4mo], range 4-14y). Children with diplegia, as a group, had shorter absolute and normalized fascicle lengths (p<0.05) but we could not refute the appropriateness of the normalization method. Other methodological issues (such as sample characteristics) might have contributed to the apparent controversy between the studies.

ut of a total of 623 patients who, over a ten-year period, underwent primary total knee replacement (TKR) without patellar resurfacing, 20 underwent secondary resurfacing for chronic anterior knee pain. They were evaluated pre-and postoperatively using the clinical and radiological American Knee Society score. The mean follow-up was 36.1 months (12 to 104). The mean knee score improved from 46.7 to 62.2 points and the mean functional score from 44.7 to 52.2 points. Only 44.4% of the patients, however, reported some improvement; the remainder reported no change or deterioration. The radiographic alignment of the TKR did not influence the outcome of secondary resurfacing of the patella. Complications were noted in six of the 20 patients including fracture and instability of the patella and loss of movement. Anterior knee pain after TKR remains difficult to manage. Secondary resurfacing of the patella is not advocated in all patients since it may increase patient dissatisfaction and hasten revision.

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Avulsion fracture of the base of the second metacarpal is an unusual injury, and the cause in the few cases reported in the literature was a fall on a volarly flexed wrist. A case of this rare injury suVered in a sport related accident by a semiprofessional rugby player is reported. It was treated with open reduction and internal fixation after failure of conservative management. (Br J Sports Med 2001;35:133-135) Keywords: avulsion fracture; metacarpal; wrist; rugby Case reportA twenty six year old semiprofessional rugby player attended the accident and emergency department complaining of pain at the dorsum of his right dominant hand. Two days previously, he had sustained a forceful hyperflexion injury of his wrist in a heavy head on tackle. Anteroposterior and lateral radiographs of his wrist were obtained but were interpreted as normal (fig 1).On review at the fracture clinic the following day, a minimally tender swelling was noticed on the dorsum of his hand at the base of the second metacarpal. The swelling was noticed to be of bony consistency and could be reduced on full dorsiflexion of the wrist. On closer inspection of the x ray films, a fracture line was suspected at the level of the base of the second metacarpal. Oblique views failed to confirm the fracture. On clinical grounds, it was decided to treat the patient as having sustained an avulsion fracture of the insertion of the extensor carpi radialis in the base of the second metacarpal.The patient was treated by applying a below elbow volar slab with the wrist in full dorsiflexion. At review after one week, the swelling was noticed to have recurred and the patient was taken to theatre. Under general anaesthetic, the hand was rotated under image intensification to establish the exact anatomy of the avulsed fragment (fig 2). Closed reduction was attempted but failed to restore the fragment. The fracture was subsequently explored through a longitudinal 5 cm incision over the osseous prominence, and the fragment was anatomically reduced and fixed with two smooth K wires (fig 3). The wrist was immobilised with a below elbow cast in neutral position for four weeks, after which the wires were removed ( fig 4) and active physiotherapy was initiated.Twelve weeks after the injury the patient had regained full range of movement of the wrist and complete function of the hand without any