Reduction by external fixator or distractor
Particularly with multifragmentary fractures, the use of an external fixator, or distractor, can provide alignment and stability for bridge plating, without disturbing the soft tissues at the fracture site.
Proximal and distal pins should be inserted carefully in order not to conflict with the later plating procedure. For this purpose, safe positions are anterolaterally or anteriorly on the femur.
If no traction table is used, folded linen bolsters under the fracture zone may facilitate reduction.
Remember that alignment of comminuted fragments does NOT need to be anatomical, and that efforts directly to manipulate them may decrease their blood supply.
Generally, soft-tissue attachments will bring these fragments into appropriate positions with adequate traction and rotation of the leg (see previous step).
Occasionally, a lag screw may be used through the plate to capture a large fracture fragment and improve its reduction.