Böhler Braun Splint — Set-up

Overview & Principles

The Böhler-Braun frame (also written Böhler Braun splint) is a fixed metal frame apparatus used in orthopaedic wards to provide balanced skeletal or skin traction to the lower limb. Named after Lorenz Böhler (Austrian trauma surgeon) and Heinrich Braun (German surgeon), it allows the injured limb to be suspended at a fixed angle of hip and knee flexion, providing continuous traction while the patient remains mobile in bed, can be nursed, and can use a bedpan. It is a hospital-based traction system — unlike the Thomas splint (which is portable), the Böhler-Braun requires a fixed frame attached to the bed and weights hanging over a pulley. Understanding its setup, indications, and complications is important for both trainee surgeons and nursing staff.

Principle — balanced suspension traction: the Böhler-Braun frame supports the limb in a position of approximately 45° hip flexion and 45–90° knee flexion; this position: (1) relaxes the hip flexors and iliopsoas (reduces proximal fragment flexion deformity in femoral fractures); (2) allows the patient to be nursed comfortably; (3) provides access for wound care; (4) the traction force acts along the line of the femoral shaft; (5) the frame itself provides support to the limb — the patient`s limb rests on the frame rather than pulling against a fixed ring (balanced suspension rather than fixed traction); skeletal traction via a Steinmann pin or Denham pin through the distal femur or proximal tibia provides the distraction force
Balanced vs fixed traction: the Böhler-Braun is balanced suspension — the leg is supported by the frame and the counterbalance of the weights; as the patient moves in bed, the traction weight moves the limb with the patient (balanced); fixed traction (Thomas splint) — the ring provides a fixed countertraction; balanced traction is more comfortable for prolonged inpatient use and more physiological

Frame Components & Set-up

Component	Description & Function	Set-up Notes
Böhler-Braun frame	A metal A-frame or inclined frame that sits on the bed under the injured limb; provides two inclined planes (the proximal incline supports the thigh, the distal incline supports the lower leg); the angle between the two planes determines the degree of knee flexion; the frame is padded with canvas slings or foam padding	The frame is placed on the mattress under the injured leg; the proximal inclined plane (thigh support) is typically at ~45° to the horizontal; the distal inclined plane (leg support) is at a steeper angle to allow knee flexion; check the frame size matches the patient`s limb length
Skeletal traction pin	A Steinmann pin (stainless steel threaded pin — most common) or Denham pin (self-tapping threaded pin — provides better fixation in cancellous bone) is inserted through bone under sterile conditions: (1) distal femur — through the lateral cortex, 2 cm proximal to the superior pole of the patella, posterior to the femur`s midline (avoids the patellofemoral joint and the popliteal vessels); (2) proximal tibia — 2–3 cm distal to the tibial tuberosity (avoids the tibial growth plate — important in children; avoids the patellar tendon insertion)	Distal femoral pin: most common for femoral shaft and acetabular fractures; higher traction forces possible; risk: popliteal vessels (too posterior) and patellofemoral joint (too anterior/distal); proximal tibial pin: used for acetabular fractures and as an adjunct to femoral shaft traction; risk: growth plate injury in children (use physeal localisation with fluoroscopy or avoid in children under 10); pin care: clean daily with chlorhexidine; check for pin loosening and infection signs
Stirrup and traction cord	The stirrup (a metal U-shaped bow) is attached to the ends of the Steinmann pin at both sides of the limb; the traction cord attaches to the apex of the stirrup and runs over a pulley at the foot of the frame (or the bed rail) and then down to a traction weight	The cord must run in a straight line from the pin through the pulley to the weight — any kink or deviation reduces the traction efficiency; the pulley must be free-running; the weight must hang freely without touching the floor or bed frame
Traction weights	Weight applied: typically 1/10 of the patient`s body weight for skeletal traction (5–10 kg for most adults); for femoral shaft fractures — start with 5 kg and adjust based on radiographic fracture reduction; countertraction provided by the patient`s body weight on the tilted bed	The foot of the bed is elevated by 15–20 cm (bed tilted, `Trendelenburg position` is NOT used — bed foot elevation only) to increase body weight as countertraction; weights must hang freely at all times — if they rest on the floor, traction force is lost; check weights are correct at each nursing assessment
Heel protection	The heel must not rest on the frame or the bed; a heel pad, gel heel protector, or free-hanging heel position must be ensured; heel pressure sores are one of the most common and serious complications of prolonged traction nursing	Check the heel at every nursing observation; use a heel protector as standard; document heel condition in the nursing record; inform the orthopaedic team immediately if any redness or breakdown is noted

Indications

Femoral shaft fractures — temporary pre-operative traction: skeletal traction on a Böhler-Braun frame is the standard inpatient management for femoral shaft fractures awaiting definitive fixation (IM nailing or ORIF); it maintains length and alignment, reduces pain and muscle spasm, controls bleeding, and facilitates nursing; in modern trauma units, the time from admission to theatre is typically <24–48 hours for femoral shaft fractures — Böhler-Braun traction bridges this period
Acetabular fractures: skeletal traction (distal femoral pin) on a Böhler-Braun frame is used to maintain the femoral head in the acetabulum and prevent superior migration of the femoral head while awaiting ORIF (typically 3–14 days); particularly important for fractures with femoral head subluxation where traction restores the joint space and reduces pressure on the cartilage
Paediatric femoral shaft fractures (>10 years, >15–20 kg): when Gallows traction is inappropriate (child too old/heavy); skeletal traction on Böhler-Braun while awaiting ESIN (elastic stable intramedullary nailing) or spica cast; proximal tibial pin used to avoid the distal femoral physis in growing children (with fluoroscopic guidance)
Hip joint conditions (historical): DDH, Perthes` disease (pre-operative traction); femoral neck fractures awaiting arthroplasty in medically complex patients; dislocated hip reduction and post-reduction stability (now managed with CT and less traction use)

Nursing Assessment & Complications

Complication	Mechanism	Prevention / Management
Pressure sores (heel, sacrum, elbows)	Prolonged immobility; pressure over bony prominences; heel is at greatest risk (calcaneum directly on frame or slings)	Gel heel protectors; regular repositioning (2-hourly minimum); pressure-relief mattress; heel inspection at every nursing check; involve tissue viability nurse if any redness develops
Pin site infection	Bacteria migrate along the pin track; Staphylococcus aureus most common; leads to osteomyelitis if not treated	Daily pin site care (chlorhexidine or saline); check for redness, swelling, discharge, loosening; remove pin if deep infection develops; pin sites should not be covered with occlusive dressings (allows moisture accumulation)
Knee stiffness / flexion contracture	Prolonged immobilisation in knee flexion; posterior capsule tightening; quadriceps wasting	Physiotherapy exercises (static quadriceps, ankle pumps) while in traction; minimise traction duration; active knee extension exercises once traction removed
Peroneal nerve palsy	Lateral fibular head pressure from the frame support or slings; common peroneal nerve at fibular neck	Pad the fibular neck; position the frame so the lateral leg is not pressed against a hard surface; foot drop check at every neurovascular assessment
DVT / PE	Prolonged bed rest and immobility; venous stasis; fracture-related hypercoagulability	LMWH thromboprophylaxis; TED stockings (uninjured leg); ankle pumps; compression devices; early definitive surgical fixation to minimise traction duration

Exam Pearls

Böhler-Braun frame: balanced suspension skeletal traction; A-frame supports the thigh (proximal incline) and lower leg (distal incline); hip ~45° flexion, knee ~45–90° flexion; skeletal traction pin + stirrup + cord + weights over pulley; foot of bed elevated for countertraction
Balanced vs fixed traction: Böhler-Braun = balanced (weights + pulley; patient moves with the traction); Thomas splint = fixed (ring provides rigid countertraction; portable); Thomas splint = field/transport; Böhler-Braun = hospital ward
Steinmann pin insertion sites: distal femur — lateral cortex, 2 cm proximal to superior pole of patella, posterior to midline (avoids popliteal vessels and patellofemoral joint); proximal tibia — 2–3 cm distal to tibial tuberosity (avoids patellar tendon; in children use fluoroscopy to avoid physeal injury)
Traction weight: approximately 1/10 body weight for skeletal traction; 5–10 kg for most adults; adjust based on radiographic reduction; weights must hang freely (not touching floor/bed)
Heel pressure sore: most common and serious nursing complication; heel must NOT rest on the frame; use gel heel protector; inspect at every nursing observation; involves tissue viability nurse if breakdown occurs
Indications: femoral shaft fractures pre-operative (maintains length, reduces pain); acetabular fractures (maintains femoral head in socket); paediatric femoral fractures (>10 years awaiting ESIN); DDH/Perthes (historical)
Pin site infection prevention: daily chlorhexidine/saline cleaning; no occlusive dressings; check for redness, discharge, loosening; early antibiotic treatment for superficial infection; remove pin if deep/osteomyelitis develops
Minimise traction duration: modern femoral shaft fractures should proceed to IM nailing within 24–48 hours; prolonged traction (days/weeks) dramatically increases DVT, pressure sore, knee stiffness, and muscle wasting risk; Böhler-Braun is a bridge to surgery, not a definitive treatment

Böhler Braun Splint — Set-up

References

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