Skeletal traction also can be achieved without fracture-table. Several alternatives are available: the large distractor, an external fixator or a custom made extension frame can be used [10–15].

The large distractor helps to provide correct length, rotation and alignment and a stable position of the fracture fragments during nail insertion [14–16]. The Schanz screws should not disturb nail insertion or placement of interlocking screws. The connections between the Schanz screws and the distractor are at a fixed angle of 90°. The large distractor therefore does not allow that its screws are positioned in an oblique direction. They are best inserted perpendicular to the cortex and/or parallel to the joints. In femoral fractures, the frame is ideally placed in the coronal plane with the screws drilled from lateral to medial. In the proximal femur, the screw is inserted in the anterior or posterior cortex at the level of the lesser trochanter; in the distal femur far distal in the condylar block [14] (Fig. 6.3). In the tibia, the proximal screw is placed posteriorly in the condylar block, the distal screw far distal in the pilon [17].

An external fixator frame can be used in the tube-to-tube technique instead of the large distractor. In contrast to the large distractor, it allows insertion of screws as joysticks in all planes. After indirect reduction, connecting bar(s) are placed between the Schanz screws and joints are tightened [18] (see also Chap.​ 18).

A custom made extension frame can be used for tibia fractures [10, 11] (Fig. 6.4). It consists of several modular parts, which are assembled on the operation table. The foot is connected to the frame with a Steinmann pin, which is drilled through the calcaneus. Depending on the position of the leg support, on which the distal femur rests, knee flexion can be changed from 60° up to 120°. Assembly of the frame takes less time than positioning the patient on the extension table. During the nailing procedure, the surgeon can improve fracture reduction by modifying the position of the modular parts of the extension frame.

Precise reduction is most important in fractures only running through one plane (transverse, oblique, spiral). Diastasis of the main fragments, their translation or malrotation may lead to delayed union and nonunion. For precise reduction of the fracture fragments, additional aids are needed. These are pointed reduction forceps or Schanz screws as joy sticks. Through small skin incisions, a correctly placed pointed reduction forceps can perfectly close a simple oblique or spiral fracture (Fig. 6.5a, b) [19, 20]. Especially in spiral fractures, exact closure of the fracture gap is important. The intramedullary canal is split over a long distance and the nail does not contribute to alignment as the fracture fragments do not encompass the nail. Alignment can be secured by interlocking screws or bolts. Schanz screws can be used as joysticks to indirectly manipulate the position of the proximal and distal fracture fragments [21]. This reduction method is especially advantageous in transverse and short oblique fractures. The proximal screw is drilled into the anterior or posterior cortex to allow unhindered nail insertion. In the distal fragment, blocking of the medullary canal by the Schanz screw is not that critical. Once the nail passed the fracture, the fracture remains reduced. For deeper insertion of the nail, the distal Schanz screw is ultimately turned back or removed (Fig. 6.6). Instead of Schanz screws, pointed reduction forceps can be placed on both fracture fragments for direct manipulation [22].

In fractures with a wedge fragment, it is recommended to reduce the gap between the wedge fragment and the main fracture fragments as much as possible. Small fracture gaps make healing with bridging callus easier and quicker. Direct manipulation of the wedge fragment can be done with a K-wire, a Schanz screw, a bone hook or a pointed reduction forceps. Exposure of the wedge fragment should be avoided whenever possible in order not to damage its blood supply.

In specific cases, precise reduction is not possible in a closed way. Soft tissue elements such as a periosteal flap or muscle may be interposed between the bone fragments. A bone fragment may be rotated; partially or completely incarcerated in the endomedullary canal. In these situations, a limited open reduction is inevitable. Vitality of soft tissues and blood supply to the bone fragments should be preserved as much as possible. Bone ends are exposed; the endomedullary canal cleared and displaced fracture fragments reduced. Reduction is done as carefully as possible with the help of reduction forceps, with a bone hook or with joysticks placed in one or several fracture fragments (see above).