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Background: Hemiplegia is the most common form of cerebral palsy. Upper limb is generally more affected than lower one. Indeed, hemiplegic children can spontaneously acquire standing and walking ability, while manipulation remains uncertain, with severe limitations in activity and participation, which define a child's functional status (International Classification of Functioning [ICF]). Several non-surgical tools are currently available to approach upper limb impairments. Studies regarding upper limb multilevel surgery in Hemiplegic Cerebral Palsy are relatively few and inhomogeneous., Aim: The aim of this study is to propose a surgical approach based on upper limb functional level and manipulation strategy and establish whether multilevel surgery can improve segmental alignment, performance and capacity, that ICF defines as activities and participation qualifiers., Design: This study is an observational retrospective study., Setting: This study involves patients who referred to the Unit of Children Rehabilitation of S. Maria Nuova Institute for Research and Care, in Reggio Emilia (Italy), over a four-year period., Population: Children affected by hemiplegic cerebral palsy who underwent upper limb multilevel surgery., Methods: For each patient, we previously defined functional use of affected upper limb applying the House classification and the Ferrari one of manipulation pattern. Patients are divided into three groups: synergic hand (House 4, 5), imprisoned hand (House 3), excluded hand (House 0). We recorded goals achievement through Goal Attainment Scale and unimanual and bimanual abilities through Melbourne Assessment of Unilateral Upper Limb Function and through Assisting Hand Assessment respectively., Results: We recorded 16 upper limb multilevel surgical interventions in 13 children and report their results., Conclusions: This study suggests that surgery can induce a segmental and/or aesthetic and/or a functional change depending on manipulation pattern. It also underlines the importance to analyze results in term of spontaneous manipulation abilities and daily use., Clinical Rehabilitation Impact: This study provides a preliminary guide to plan surgery in relation to segmental deformities and overall manipulation pattern and describes their feasible improvement measures. It also suggests the most useful tools to record goal achievements in modifying manipulation function. Further controlled, randomized and prospective studies are required to support this idea.