Bohler-Braun Frame - 20 Marks Answer

1. Introduction and Historical Background

• Lorenz Bohler - Austrian trauma surgeon
• Heinrich Braun - German surgeon

2. Description of the Frame

3. Principle - Balanced Suspension Traction

• The limb is supported at approximately 45° hip flexion and 45-90° knee flexion
• This position:
  1. Relaxes hip flexors and iliopsoas - reduces the tendency of the proximal fragment to flex in femoral shaft fractures
  2. Allows the traction force to act along the line of the femoral shaft
  3. The frame supports the weight of the limb (balanced suspension) - the patient is not pulling against a fixed ring
  4. Allows comfortable nursing, bedpan use, and wound access
• Skeletal traction is applied via a Steinmann pin, Denham pin, or Kirschner wire through bone, with weights hanging over pulleys

4. Positions of the 4 Pulleys (Bohler's Modification)

5. Pin Insertion Sites

For Femoral Shaft Fractures:

• Proximal tibia pin - 2-3 cm distal to the tibial tuberosity (avoids patellar tendon; in children use fluoroscopy to avoid physeal injury)
• Distal femur pin - Through the lateral cortex, 2 cm proximal to the superior pole of the patella, posterior to midline (avoids popliteal vessels and the patellofemoral joint)

For Tibial/Leg Fractures:

• Pin through the calcaneal tuberosity

Traction Weight:

• Approximately 1/10 of body weight (roughly 5-10 kg for most adults)
• Weights must hang freely - not touching the floor or the bed

6. Indications

A. With Traction (Skeletal or Skin):

1. Fracture shaft of femur - definitive conservative management or temporary pre-operative traction awaiting IM nailing
2. Supracondylar fracture of femur
3. Fractures of the tibia and fibula with displacement/overlap
4. Hip fractures - temporary pre-operative traction (controversial)
5. Fractures with significant muscle spasm and overlap requiring reduction
6. Open fractures of lower limb while awaiting definitive surgery
7. Post-operative support and immobilization

B. Without Traction:

1. Compound (open) fractures with no overlap - for dressing, wound care, and immobilization
2. Soft tissue injuries of the leg
3. Post-operative rest and elevation
4. Burns of the lower limb
5. Infected wounds requiring repeated dressing changes

7. Setup Procedure (Step-by-Step)

1. Explain procedure to patient and obtain consent
2. Assemble the frame and attach securely to the bed frame (not just the mattress)
3. Position slings of canvas or gamgee under the thigh and leg - leave heel free (to avoid heel sores)
4. Insert the traction pin under aseptic conditions (Steinmann/Denham/K-wire) through the appropriate bone site
5. Apply Bohler stirrup to the pin
6. Attach traction cord to the stirrup, pass over the appropriate pulley
7. Hang traction weights (usually 5-10 kg, ~1/10 body weight) - weights must hang freely
8. Check limb alignment clinically and confirm on X-ray
9. Apply foot piece to prevent equinus deformity (foot drop prevention)
10. Check neurovascular status of the limb distally

8. Advantages

1. Stable, continuous traction - maintains reduction without patient cooperation
2. Allows excellent nursing access - for pressure area care, bedpan use, wound care
3. Balanced suspension - more comfortable than fixed traction
4. Permits knee and ankle exercises (quadriceps, ankle dorsiflexion) to prevent stiffness
5. Can be used for both skeletal and skin traction
6. Multiple pulley positions allow use for different fracture levels
7. Permits monitoring of the neurovascular status of the limb
8. Allows easy wound care in compound fractures

9. Disadvantages / Limitations

1. Hospital-based only - cannot be used as an ambulance or transport splint (unlike Thomas splint)
2. Cumbersome - difficult in situations where compactness is required
3. Requires skilled nursing staff for maintenance and monitoring
4. Prolonged immobilization - risks of DVT, pressure sores, pneumonia, muscle wasting
5. Pin site complications with skeletal traction
6. Fracture disease (joint stiffness, muscle wasting, osteoporosis) with prolonged use
7. In modern trauma centres, mostly replaced by operative fixation (IM nailing) within 24-48 hours

10. Complications

A. Pin Site Complications:

B. Nursing/Immobilization Complications:

C. Traction-Specific:

• Over-distraction - non-union if too much weight
• Under-traction - malunion/shortening if insufficient weight
• Vascular injury - if pin misplaced (e.g., popliteal artery for distal femur pin)
• Nerve injury - common peroneal nerve for proximal tibia pin

11. Nursing Care (Maintenance on Bohler-Braun Frame)

1. Heel inspection at every nursing observation - heel must NOT rest on the frame; use gel heel protector
2. Pin site care daily - clean with chlorhexidine or normal saline; check for redness, discharge, loosening
3. Weights hanging freely - check at every round; not touching the floor or bed
4. Foot drop prevention - foot piece in position; active dorsiflexion exercises
5. Pressure area care - 2-hourly repositioning; pressure-relief mattress
6. Quadriceps exercises - static contractions, straight leg raises (when permitted)
7. Ankle exercises - to prevent DVT and maintain range of motion
8. DVT prophylaxis - anti-embolic stockings (on unaffected limb), LMWH as prescribed
9. Regular neurological checks - sensation and movement of toes
10. Vascular checks - peripheral pulses, capillary refill, temperature of toes

12. Comparison: Bohler-Braun Frame vs Thomas Splint

13. Current Status in Modern Orthopaedics

• Centres with limited surgical resources
• Patients medically unfit for immediate surgery
• Pathological fractures awaiting appropriate surgery
• Developing countries where conservative management remains the primary approach

• Named after Bohler (Austrian) and Braun (German)
• Principle = balanced suspension traction at 45° hip + 45-90° knee flexion
• Traction weight = 1/10 body weight
• 4 pulleys for different fracture levels
• Most common complication = heel pressure sore (nursing)
• Most serious pin complication = pin track infection -> osteomyelitis
• Difference from Thomas splint = hospital-based, balanced (not fixed), knee flexed
• Pye's Surgical Handicraft, 22nd Edition (Traction Systems, Chapter 15)