Your child has been treated for clubfoot. This information explains how a boots and bar orthosis works and how to look after your child.
What is clubfoot?
Clubfoot is a malformation of the foot that is present at birth. The malformation can affect one foot or both feet.
Treatment for this condition begins early after birth using the Ponseti method of serial casting. Once full correction is achieved, your child will be prescribed an orthosis (brace) to maintain the foot or feet in the corrected position. Proper compliance with the brace reduces the risk of the clubfoot recurring.
The boots and bar orthosis
After your physical therapist or doctor has assessed that full correction of the feet/foot has been achieved, they will prescribe a boots and bar orthosis. The orthosis is two open-toed leather boots connected by a metal bar. The brace holds your child's feet turned outwards and in the corrected position. Your therapist will determine the degree of outward rotation at which the feet will be held in the brace.
The boots and bar orthosis is also called a foot abduction orthosis or a Denis Browne splint.
An orthotist fits your child for the orthosis
An orthotist is a person who has been trained in the making, fitting and assessing orthoses. Your orthotist will do the following:
- fit your child with an orthosis on the day the final cast is removed
- set the amount of rotation in the orthosis, following the physiotherapist/doctor's orders
- show you how to put on the orthosis and make sure that it fits properly
- answer your questions and address any concerns you have about the orthosis
Using the orthosis
At the first fitting, your orthotist will show you how to put on the boots and bar orthosis and make sure that it is fitting properly. It is extremely important that your child's foot does not move within the boot.
Putting on the orthosis
- For the first few weeks, use a thin stockinette to avoid skin breakdown.
- Make sure the tongue is pulled up high to ensure the ankle strap secures the heel in the boot. Use your thumb to keep pushing in the tongue until the ankle strap is holding the heel firmly down in the base of the boot.
- The ankle strap should be through the slot in the side of the boot, then buckled in the marked hold. Your child will likely have some minor swelling in the first few days after the cast is taken off. When the swelling goes down, the strap may need to be tightened to the next hole over time. Keep in mind that the strap will stretch over time as well.
- Fasten the straps up and laces firmly, but not too tightly.
Your baby may be more fussy than usual for the first day. They will get used to the brace. This is a new but normal position for your baby. We recommend leaving the brace on for the first 24 hours to allow the baby to accommodate to the new position.
Checking the fit of the orthosis
- After buckling the ankle strap, slide your pinky finger along the side of the boot and check to see that the bottom of the heel is touching the bottom of the boot.
- Open the stockinette at the toes to check for circulation. You can do this by pressing the skin on the toes with your finger. The skin should turn white, but become pink again. The skin should not be purple.
- After buckling and lacing the boots, gently tug down on them. The heel should not slide up or down the boot.
- If the toes slide back in the boot, this is a sign that the orthosis is not holding the heel down. Try refitting the boot again. If the problem continues call your orthotist to tell them this is happening.
Your child will need to wear the orthosis until they are four to five years old
For the first three months, your child will be required to wear the orthosis for 23 hours each day. You can take off the orthosis for one hour each day to allow for bathing and normal touch and play.
After three months, the physiotherapist will reassess your child. The physiotherapist will let you know when your child is ready to wear the orthosis for a shorter time (12 to 15 hours) each night.
Creating a normal nightly routine of brace wear will ensure your child is comfortable and accepting of their brace as normal. It is important for your child to wear the orthosis every night until they are four to five years of age. New orthoses will be needed as your child grows.
Skin care
After the first 24 hours
The day after the first fitting, take your child's boots and socks off. After you remove the boots, the skin may be red or pink due to the tightness. This is normal if the red area is spread over a large area of the foot. Small localized dark red areas that do not go away within 20 to 30 minutes may be a sign of a blister or pressure. Please contact your orthotist if this is a concern.
First bath
Clean your child's legs from the casting material using baby oil in the bath water. Be sure to rinse any soap off well with water. Avoid creams or lotions on the skin. A light dusting of cornstarch helps to make your child more comfortable and absorb sweat. Depending on how much your child perspires, you may want to change their socks two to three times a day. Dry skin should be treated with petroleum jelly over all affected areas.
When you start using regular socks, check that the seam is not causing any pressure on the inside of the foot. If it does, you may need to turn the socks inside out or buy seamless socks. Make sure the sock is long enough to fold the top edge over the boot cuff. This will avoid having the sock slip down in the boot or having the elastic dig into the skin.
Problems to look out for
If any of the following occur, contact your orthotist:
- skin irritation on the foot or feet
- problems with the fit of the orthosis
- movement of the heel within the boots
- extreme discomfort in your child
If any of the following occur, take off the orthosis and contact your orthotic clinic to make an immediate appointment:
- excessive redness that does not go away in 20 to 30 minutes
- blisters
- bleeding
- skin breakdown
At SickKids
Cost of the orthosis
The price for the orthosis is approximately $384. The Assistive Devices Program (ADP) covers 75% of this cost. Therefore, you are responsible for paying the remaining 25%, which is approximately $96.
Speak to your orthotist for further information on pricing.
Splint donation
Children all over the world are born with clubfoot. In the isolated areas of developing countries, children do not have ready access to splints and braces.
The Centre for Orthotics and Medical Devices at the Hospital for Sick Children accepts donations of used braces to send to developing countries.