Fifteen quadriplegic (tetraplegic) patients from the spinal injuries unit of the austin hospital have had surgery to improve function in 17 of their upper limbs. Changes in strength, function, subjective ratings and the influence on 198 activities of daily living are reviewed. The posterior third of the deltoid muscle was transferred into 8 triceps tendons to provide active elbow extension in seven patients. Six patients had transfers of forearm muscles to provide grasp and lateral pinch or active extension of wrist and fingers. Other operations included transfer of the latissimus dorsi to the forearm producing elbow flexion, medial advancement of the anterior deltoid origin improving shoulder control (an operation which has not been described previously), and tenodesis for stabilizing the wrist. The objective results were satisfactory in 12 patients. Eleven patients had either good or excellent subjective results. The maximum force of active elbow extension achieved was 6.8 kg and the peak grip strength reached was 10.5kg. Six patients achieved subjective results higher than would have been expected from objective assessment. All patients benefited in some way. 13 patients felt that surgery was worthwhile and no patient lost appreciable function. The results of this series indicate that upper limb surgery has a definite place in rehabilitation of the quadriplegic patient. Improved surgical technique may reduce the time required for postoperative rehabilitation and thus make these procedures feasible for a larger number of patients.

SummaryThe options for surgical reconstruction of the quadriplegic upper limb are clarified by a new international classification of each limb independently, based upon· the lowest functioning key muscle and residual sensation. Surgical restoration of active elbow extension, of pinch, and of grasp is now an accepted part of rehabilitation. This additional function may be achieved by transfer of a non-essential muscle, by tenodesis, or occasionally by arthrodesis. The techniques available for each group of the new international classification are described.

SummaryPlastic surgeons have contributed to the understanding of pressure sore patho physiology and prophylaxis. Increasingly sophisticated surgical techniques such as myocutaneous or innervated flaps add to the reliability and durability of repairs.The majority of quadriplegics may benefit from surgical restoration of active elbow extension, lateral pinch and grasp. Prolonged postoperative care in bed or im mobilisation of the upper limb demands that patients should understand fully all that the reconstructive procedure involves. The nature and importance of subsequent rehabilitation must be appreciated by the patient so that he will be motivated to achieve the best possible result. Functional electrical stimulation may find an in creasing role in the years to come. The pathophysiology an4 prophylaxis of pressure sores Prolonged pressure, especially over bony prominences, causes ischaemic injury to tissues deprived of protective sensation. This is the primary cause of a pres sure sore. Other factors which have been implicated include the adverse effect of Correspondence to Mr J. A.