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of the knee joints had been deliberately produced elsewhere, in order to 'facilitate
standing and walking'. However, this method has proved to increase rather than diminish
the paraplegic's disability, as it makes sitting in a wheelchair, motor tricycle or car most
difficult or even impossible and may diminish the chances of re-employment. The most
incapacitating contractures in lower cord lesions are flexion contractures of the hips,
resulting in backwards distortion of the pelvis. These contractures develop if the patient
is allowed to lie for too long in lateral position with flexed hips and knees. In anterior
horn lesions, involving the trunk and shoulder muscles, faulty positioning of the patient
is responsible for the development of scoliosis, even if the lesion is symmetrical. This
applies in particular to children and adolescents. I have seen the most gruesome forms of
scoliosis and flexion contractures of the lower limbs on polio victims during my visits to
the African countries, and Professor Huckstep of Kampala, in particular, has drawn
attention to this condition (1968).
Care and treatment of the paralysed hand andfingers in tetraplegics
This has been a neglected subject for many years, caused mainly by delayed admission
of traumatic tetraplegics to Spinal Injuries Centres, but also by inadequate measures
taken in the acute stages in Spinal Units, to prevent oedema and contractures of the
metacarpophalangeal and interphalangeal joints. As a result of the interruption of the
vaso-constrictors in these high lesions, the vaso-motor control is crippled and oedema
develops below the level of the lesion, including hand and fingers. Collagen is deposited
in the oedema fluid, and if the oedema is not overcome by frequent movements of the
wrist, metacarpophalangeal and interphalangeal joints and fixing the arm and hand for
some periods in vertical position to counteract oedema by physiotherapist as well as
nurses and instructed visitors, the deposited collagen becomes transformed into fibrous
tissue and loss of elasticity of ligaments, fasciae and joint capsules follows, resulting in
contractures. This mechanism has been well described by Sharrard (1967). In this
connection it may be mentioned that in elderly tetraplegics oedema followed by contrac
tures of the metacarpophalangeal and interphalangeal joints sometimes develops in spite
of regular and intensive physiotherapy by passive movements. The mechanism of this
complication is still obscure but in some of these patients this can be prevented by bring
ing the arm into vertical position.
It is essential that before physiotherapy to the hand and fingers is commenced, a
detailed assessment of all muscles of the upper extremity is carried out. This applies, in
particular, to complete lesions of the cervical cord at C6 and below C6 and Cy where
varieties in the muscular deficit occur due to the multi-segmental innervation of the
forearm, hand and finger muscles. Attention has already been drawn to the prevention
of flexion contractures of the forearm as the result of the paralysis of triceps, which can be
absolutely avoided by proper positioning of the forearm in extension to counteract the
overaction of the strongly acting biceps in these patients. In certain lesions at or below C6
the extensor carpi radialis longus may be active while the brevis is paralysed. Therefore,
the hand will be pulled in extreme radial abduction, if faulty positioning of the hand is
not prevented.
