3.1 Bruner Flap

The Bruner flap is a commonly performed access incision and the modified version involves a broader flap. The most common mistake in flap design is making the angle of the flap too acute and therefore risking necrosis of the flap tip. This can be avoided if the flaps are designed with broad curved tips (Fig. 3‑1). This is a critical step because if the flaps fail over a tendon repair, the patient could develop tendon exposure and subsequent infection.

In children, Bruner-type incisions should be used as midlateral incisions which can often migrate volarly with growth, resulting in flexion contractures (Fig. 3‑2).

3.2 Midlateral Incision

The patient in Fig. 3‑3 has sustained flexor zone 2 tendon injuries to four fingers secondary to a knife laceration. As his hand was clenched at the time, the level of tendon injury differs from the level of skin injury when the hand is relaxed. Midlateral access was performed in all digits within 45 minutes, before repairs were performed (Fig. 3‑3). The incision is marked by flexing the digit and marking a point at the end of the flexion crease at each joint (Fig. 3‑4).

The midlateral approach is preferred by some hand surgeons as it avoids problems with flap necrosis as one broad flap is raised. It also avoids additional scarring over the site of the flexor tendon repair.

In the midlateral approach, the dorsal branch of the digital nerve is at risk and should be protected.