Treatment of Midshaft Clavicle Fractures: Application of Local Autograft With Concurrent Plate Fixation  Erik L. Slette, B.A., Jacob D. Mikula, B.S., Travis Lee Turnbull, Ph.D., Thomas R. Hackett, M.D.  Arthroscopy Techniques  Volume 5, Issue 3, Pages e557-e562 (June 2016) DOI: 10.1016/j.eats.2016.02.008 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 The patient is placed in the beach-chair position (left shoulder) with the axilla and hand excluded from the surgical field. A 10-cm incision is made with a No. 15 scalpel blade superior to the site of clavicle injury. Arthroscopy Techniques 2016 5, e557-e562DOI: (10.1016/j.eats.2016.02.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Sharp dissection is performed with a No. 15 scalpel blade to allow for visualization of the fracture site. A minimal amount of soft tissue is removed to preserve the soft-tissue envelope around the fracture site (left shoulder). Arthroscopy Techniques 2016 5, e557-e562DOI: (10.1016/j.eats.2016.02.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 Bone reduction forceps are used to provisionally reduce the butterfly fragment in preparation for precontoured fixation plate sizing (left shoulder). Arthroscopy Techniques 2016 5, e557-e562DOI: (10.1016/j.eats.2016.02.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 In this particular case, a K-wire is drilled into the superior aspect of the butterfly fragment to ensure the stability of the reduced fragment (left shoulder). Arthroscopy Techniques 2016 5, e557-e562DOI: (10.1016/j.eats.2016.02.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 In this patient, an 8-hole precontoured titanium plate is used based on the length of the clavicle and extent of the pathology (left shoulder). The plate size is selected so that 4 cortices are drilled on each side of the fracture site. Arthroscopy Techniques 2016 5, e557-e562DOI: (10.1016/j.eats.2016.02.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 With the precontoured plate used as a guide, a 2.8-mm drill bit is used to ream pilot holes in the superior aspect of the clavicle in preparation for screw placement (left shoulder). Arthroscopy Techniques 2016 5, e557-e562DOI: (10.1016/j.eats.2016.02.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 A dental pick is used to harvest bone autograft from the flutes of the drill bit after the drilling of each pilot hole. Arthroscopy Techniques 2016 5, e557-e562DOI: (10.1016/j.eats.2016.02.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 After harvesting of the bone autograft from the flutes of the drill bit, the autograft is placed in a sterile cup (with no saline solution) for preservation. Saline solution is not added to the cup to avoid washing away important osteogenic factors contained within the autograft. Arthroscopy Techniques 2016 5, e557-e562DOI: (10.1016/j.eats.2016.02.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 9 A surgical depth-measurement device is used to determine the depth of the medial pilot hole before screw placement (left shoulder). Arthroscopy Techniques 2016 5, e557-e562DOI: (10.1016/j.eats.2016.02.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 10 A screwdriver (Acumed) is used to place screws in a laterally located pilot hole (left shoulder). The screws are placed in either a corticocancellous locking or non-locking configuration. Arthroscopy Techniques 2016 5, e557-e562DOI: (10.1016/j.eats.2016.02.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 11 Fluoroscopy is used to confirm the position and length of the fixation screws (left shoulder, posterior-anterior view). Arthroscopy Techniques 2016 5, e557-e562DOI: (10.1016/j.eats.2016.02.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 12 The bone autograft that accumulated in the sterile cup (Fig 8) is packed within the posterior aspect of the fracture site with a forceps (left shoulder). Arthroscopy Techniques 2016 5, e557-e562DOI: (10.1016/j.eats.2016.02.008) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions