Hand Surgery

The Royal North Shore Hospital’s Department of Hand and Peripheral Nerve Surgery has a clinical and research focus. It provides high level care to patients with complex hand and peripheral nerve problems, while also advancing the science of the speciality through clinical and basic scientific research.

With an emphasis on clinically relevant topics, the department undertakes surgical outcome reviews, surgical technique developments, multi-centre international trials, comparative anatomy studies, and publishes case reports.

Our team has specialised clinical interests in congenital hand anomalies, brachial plexus injuries, tetraplegia and spasticity, and therefore much of the research undertaken focuses on these areas. Our work and research in these fields is recognised worldwide, with Professor Michael Tonkin and Dr Claudia Gschwind regularly invited to present findings at international congresses.

In a career focused on congenital hand surgery and its associated research, Professor Tonkin co-developed the internationally used eponymous Oberg Manske Tonkin Classification of Congenital Anomalies of the Hand and Upper Limb. This system now provides the basis of many research projects worldwide in congenital hand surgery.

David Stewart

Senior lecturer, University of Sydney
Supervisor of Plastic Surgery Training, RNSH Department of Hand Surgery
Visiting Medical Officer at RNSH and the Children’s Hospital Westmead
Reviewer of the Journal of Hand Surgery (American)
Reviewer of the Journal of Hand Surgery (European)
Reviewer of the ANZ Journal of Surgery

Richard Lawson

Head of the RNSH Department of Hand Surgery
Lincoln Director of Hand Surgery Research at RNSH
Associate Editor of the Journal of Hand Surgery (American)
Reviewer of the Journal of Hand Surgery (European)

The Department of Hand Surgery and Peripheral Nerve Surgery includes six consultant surgeons with orthopaedic, plastic and general surgical backgrounds, and specific training in hand surgery. The department also has three hand surgery fellows, two orthopaedic surgery registrars, one plastic surgery registrar and a resident medical officer, along with a research officer and department secretary. Fellows and registrars join the department for six or 12 month positions and are encouraged to undertake a research project during their term in the department.

Hand surgery research projects are overseen by:

  • Dr Anthony Beard - Consultant Hand Surgeon
  • Dr Claudia Gschwind - Consultant Hand Surgeon
  • Dr Mark Hile - Consultant Hand Surgeon
  • Dr Richard Lawson - Consultant Hand Surgeon, Head of Department, Lincoln Centre Director of Hand Surgery Research
  • Dr James Ledgard - Consultant Hand Surgeon
  • Dr David Stewart - Consultant Hand Surgeon, RNSH SERT Surgical Academic Lead
  • Professor Michael Tonkin - Professor Emeritus of Hand Surgery, University of Sydney
  • Belinda Smith - Research Officer

Research projects are run in collaboration with:

  • RNSH departments, including physiotherapy, orthopaedic and traumatic surgery, the Spinal Injuries Unit and the Multi-Disciplinary Spasticity Clinic
  • The Kolling Institute, including the Murray Maxwell Biomechanics Research Laboratory, the Sutton Laboratories and the Sydney Clinical Skills and Simulation Centre
  • The Children’s Hospital at Westmead
  • North Shore Private Hospital
  • University of Sydney’s Master of Surgery and Master of Philosophy programs
  • Taronga Zoo
  • International hospitals and universities, such as the ERASMUS Medical Centre in Rotterdam, Netherlands and the Loma Linda University, California, USA.

Hand and Peripheral Nerve Surgery studies fall into three categories:

1. Anatomical and biomechanical research

Basic scientific research projects focus on the biomechanics and strength of tendon repairs and rehabilitation, as well as the anatomy of the nervous system. Our projects investigate the strength of suture material and clinical techniques to improve surgical repairs of tendon injuries.

Our research on the nervous system is contributing to

international advances in surgical techniques such as nerve transfers in tetraplegia. This progress is game-changing for patients who can now access surgical options to regain function.

2. Clinical studies and case reports

The Department provides care for a unique group of congenital, brachial plexus, tetraplegia and spasticity patients alongside the daily elective and trauma patients. This provides excellent opportunities to review clinical procedurs, assess their efficacy and investigate further options for care. These studies include reviewing surgical approaches in brachial plexus surgery, documenting the Carer Burden Score in spasticity patients and investigating the outcomes of more recent surgical developments for scaphoid non-union treatment. We undertake numerous research projects with the assistance of patients treated for congenital anomalies. These look at the basis of the anomaly, compare surgical treatments, and assess the patient outcomes and satisfaction.

3. Literature reviews

An increasing emphasis is being placed on evidence-based medicine and systematic reviews of the scientific literature. These reviews particularly provide valuable information given the huge range of conditions and surgical treatments. Our team has undertaken reviews of congenital hand surgery treatments, with the reviews then published as textbook chapters and the authors invited to present their findings at international congresses.

Cheng AMY, Cheng HS, Smith BJ, Stewart DA. Neutrophilic Dermatosis of the Hands: A review of 17 cases. J Hand Surg Am. 2018;43(2):185.e181-185.e185. doi: 10.1016/j.jhsa.2017.08.027.

Donald S, Niu R, Jones CW, Smith BJ, Clarke EC, Lawson RD. Effects of removal and reinsertion of headless compression screws. J Hand Surg Am. 2018; 43(2):139-145. doi: 10.1016/j.jhsa.2017.10.002. - Awarded “Editor’s Choice” status

Marshall TG, Sivakumar B, Smith BJ, Hile MS. Mechanics of metacarpophalangeal joint extension. J Hand Surg Am. 2018; 43(7):681.e1-681.e5. doi: 10.1016/j.jhsa.2017.12.010.

Sefton AK, Smith BJ, Stewart DA. Cost comparison of collagenase clostridium histolyticum and palmar fasciectomy for treatment of Dupuytren's contracture. J Hand Surg Asian Pac Vol. 2018; 23(3):336-341. doi: 10.1142/S2424835518500327.

Mende K, Tonkin MA. The Austrian Flag: Severe carpal tunnel syndrome. A case report. J Hand Surg Asian Pac Vol. 2018; 23(3):412-414. doi: 10.1142/S2424835518720268.

Rastogi P, Stewart DA, Lawson RD, Tremblay DM, Smith BJ, Tonkin MA. Cadaveric dissection of the axillary nerve: an investigation of extra-muscular and intra-muscular branching patterns. J Hand Surg Asian Pac Vol. 2018; 23(4):533-538. doi: 10.1142/S2424835518500546.

Graham DJ, Clitherow HDS, Singh HP, Smith BJ, Clarke EC, Tonkin MA. The effect of extensor tendon adhesions on finger motion. J Hand Surg Am. 2019; 44(10):903.e1-903.e5. doi: 10.1016/j.jhsa.2018.12.011.

Mende K, Tonkin MA. Congenital great toe hypoplasia equivalent to a grade 3 hypoplastic thumb in a patient with VACTERL association. J Hand Surg Asian Pac Vol. 2018; 23(4):605-606. doi: 10.1142/S2424835518720402.

Mende K, Suurmeijer JA, Tonkin MA. Surgical techniques for reconstruction of the hypoplastic thumb. J Hand Surg Eur Vol. 2019; 44(1):15-24. doi: 10.1177/1753193418793579.

Smith NC, Sivakumar B, Bellity JP, Tremblay DM, Lawson RD. Interosseous membrane reconstruction utilizing flexor digitorum superficialis autograft. Tech Hand Up Extrem Surg. 2019; 23(3):122-127. doi: 10.1097/BTH.0000000000000237.

Haines M, Baba M, Stewart DA. Iatrogenic femur fracture following medial femoral condyle flap harvest. J Hand Surg Am. 2020 Sep;45(9):885.e1-885.e3. doi: 10.1016/j.jhsa.2019.12.001.

Gschwind CR, Yeomans JL, Smith BJ. Upper limb surgery for severe spasticity after acquired brain injury improves ease of care. J Hand Surg Eur Vol. 2019; 44(9):898-904. doi: 10.1177/1753193419866595.

Ledgard JP, Gschwind CR. New developments in reconstructive upper limb surgery for tetraplegia: evidence for their efficacy. J Hand Surg Eur Vol. 2020;45(1):43‐50. doi:10.1177/1753193419886443

Vanhees M, Cardillo ND, Hile MS. The effect of knot position in Adelaide flexor tendon repair. J Hand Surg Eur Vol. J Hand Surg Eur Vol. 2020;45(3):303‐304. doi:10.1177/1753193419889297

Mende K, Watson A, Stewart DA. Surgical treatment and outcomes of syndactyly: A systematic review. J Hand Surg Asian Pac Vol. 2020;25(1):1‐12. doi:10.1142/S2424835520300017

Chahal H, Athreya P, Stewart DA. Acute Carpal Tunnel Syndrome as First Presentation of Amyloidosis. Australas J Plast Surg. [Accepted for publication, December 2020]

Hand Surgery related information

As well as the 150+ international and local fellows that the Department has trained since the 1980s, the department also regularly hosts Visiting Professors and welcomes observers from hand surgery units nationally and internationally. Each participates in research, through involvement at RNSH or by delivering presentations of their work undertaken at their home institutions.

Drs Michael Tonkin, Richard Lawson, David Stewart and Anthony Beard have participated in annual hand surgery missions to deliver surgical services to developing areas and provide an educational program to these local surgeons. These include annual visits to Vietnam and Cambodia under Rotary and Orthopaedic Outreach programs respectively, as well as to China. The Department consultants hold positions in international, national and state hand surgery groups, and are involved in the scientific programming of the congresses held annually.

Regular specialised educational courses are also organised at Royal North Shore Hospital by the department with invited lecturers, including the Australian Hand Surgery Society Hand and Forearm Flap Course and the Australian Hand Surgery Brachial Plexus Dissection Course. These courses provide experience to many national and international hand surgeons and continue to provide inspiration for research.

More information can be found on the department website www.rnshhand.org

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