We explain a retraction suture technique as a useful method for gaining improved exposure in the upper extremity surgery—specifically in this example, the humeral shaft and distal humerus. This surgical tip eliminates the need for bulky retractors, reduces surgical field clutter, and enhances the surgeon’s visualization of relevant local anatomy.

Humeral shaft fractures account for ~3% of all fractures in the United States.1–3 In young patients, humeral shaft fractures are typically caused by high-velocity or penetrating trauma. In older patients, this injury is typically the result of a fall.2 Nonoperative intervention through bracing, splinting, or casting is an appropriate treatment modality in isolated fractures of the humeral diaphysis.1 Acceptable closed treatment parameters are well established with 3 cm of shortening and angulation <30 degrees in the valgus and varus directions and 20 degrees in the sagittal direction.2 Indications for surgical intervention include failed nonoperative treatment, obese body habitus interfering with bracing, neurovascular injury, open fracture, or polytrauma, including lower extremity fractures or ipsilateral upper extremity fractures. The 2 main surgical options for humeral shaft fractures include intramedullary nailing and open reduction and internal fixation (ORIF) with plate and screw fixation with or without cerclage.1–3 Of these, ORIF is most commonly used.1

There are 2 main approaches for ORIF of humeral shaft fractures—anterolateral and posterior. The choice of approach is based on fracture location, patient factors, and additional injuries to the radial nerve.3 During ORIF, the goals include maximizing exposure for reduction while protecting essential neurovascular structures.

Fractures of the distal humerus account for roughly 2% of all fractures with an incidence rate of 5.7 per 100,000 people.4 The mechanisms of these fractures mirror those of humeral shaft fractures, as does the nonoperative management. However, when surgery is indicated, ORIF is the standard of care. Almost all approaches to distal humerus fractures utilize a posterior incision. With this approach and fracture pattern, it is essential to visualize and avoid the surrounding neurovascular structures.5

TECHNIQUE

We describe the use of superficial retraction sutures during humeral shaft or distal humerus fracture fixation to improve visualization for subsequent deeper dissection. When using the posterior approach for ORIF, the patient is positioned in either the lateral decubitus or prone position. The surgeon may prefer to mark the radial and ulnar sides with an “R” and “U,” and a line is drawn along the middle posterior arm from the olecranon to the proximal humerus (Fig. 1). When using an anterolateral approach, a curved incision is planned drawing from just lateral of the elbow crease proximally to the coracoid process pending the location and fracture pattern (Fig. 2). In both approaches, the skin is incised, and the underlying fascial plane developed. The skin is retracted with self-retaining Weitlaner retractors proximally and distally, and the subcutaneous tissues are dissected to form thick skin flaps.

FIGURE 1:

The posterior approach to the humerus using retraction sutures (white arrows).

FIGURE 2:

The modified anterolateral approach to the humerus using retraction sutures (white arrows).

After the skin flaps are formed, the retraction sutures are placed to retract the skin, eliminating the need for retractors. The skin flaps are elevated and then sewn to the adjacent skin using 2-0 nylon sutures. To do this, a suture is sewn through an epidermal and dermal skin bite ~1 cm from the edge of the skin flap. The surgeon then may tailor the direction and degree of countertraction to what best suits the case. The needle is then threaded through the edge of the skin flap and tied to retract the skin flap edge onto the adjacent skin (Fig. 3). At least 2 retraction sutures are placed on each side of the skin incision; more can be added if necessary. They are spaced evenly to distribute the force of retraction, and tails are kept long for easy extraction during closing at the end of the case. After placement of the retraction sutures, the Weitlaner retractors are no longer necessary and are removed.

FIGURE 3:

At least 2 retraction sutures (white arrows) are placed on each skin flap.

EXPECTED OUTCOMES

Our retraction suture technique is easy to execute and has several benefits. Fixation of humeral shaft and distal humerus fractures with ORIF is challenging, and intraoperative assistance is routinely needed. This procedure replaces the assistant’s retraction task, allowing the assistant to aid in other critical components of the case and decreasing the burden on the surgeon. Without the retraction task, assistants are more capable of managing exposure with debridement and mobilization of soft tissues, permitting the surgeon to better visualize the fracture site. Once the fracture site is visualized, the assistants are free for fracture reduction and hardware placement. Surgical exposure is also enhanced as the operative field is clear of hands or instruments that may obstruct the view of the surgeon. This allows for greater visualization of the humerus and adjacent neurovascular structures during deep dissection. In addition, a previous study demonstrated that the use of retractors in upper extremity surgery causes dose-dependent damage to the surrounding neurovasculature.6 The retraction suture technique we present here develops a stable retraction of tissues with the aim of mitigating the damage caused by typical retractors.

COMPLICATIONS

If not executed correctly, potential complications of this technique include improper anchoring of sutures, increased shear forces on the skin, and inadequate visualization. In addition, this method will be less efficacious with thick fibrous tissue and small skin flaps.

CONCLUSION

Retraction sutures on the superficial skin flap develop excellent superficial exposure for the humeral shaft and distal humerus fracture fixation. They may be used in other surgical circumstances requiring stable skin retraction as well. The use of retraction sutures is a quick modification that enables the surgeon to better visualize the operative field, reduces surgical field clutter, and allows for customizable countertraction tailored to the case. As a result, surgeons can better visualize relevant anatomy in the surgical field in an effort to reduce the risk of iatrogenic complications.

REFERENCES 1. Gottschalk MB, Carpenter W, Hiza E, et al. Humeral shaft fracture fixation: incidence rates and complications as reported by American Board of Orthopaedic Surgery Part II candidates. J Bone Joint Surg Am. 2016;98:e71. 2. Carroll EA, Schweppe M, Langfitt M, et al. Management of humeral shaft fractures. J Am Acad Orthop Surg. 2012;20:423–433. 3. Walker M, Palumbo B, Badman B, et al. Humeral shaft fractures: a review. J Shoulder Elbow Surg. 2011;20:833–844. 4. Robinson CM, Hill RM, Jacobs N, et al. Adult distal humeral metaphyseal fractures: Epidemiology and results of treatment. J Orthop Trauma. 2003;17:38–47. 5. Lauder A, Richard MJ. Management of distal humerus fractures. Eur J Orthop Surg Traumatol. 2020;30:745–762. 6. Traver JL, Guzman MA, Cannada LK, et al. Is the axillary nerve at risk during a deltoid-splitting approach for proximal humerus fractures. J Orthop Trauma. 2016;30:240–244.