FAB Tips and Tricks

June 3, 2005

We used to post this all the time for anyone who was new, but since

Kori has been computer handicapped lately I thought I would put this

out there for any parents who are new to the Foot Abduction Bracing

part of their child's treatment.

FAB/DBB Tips and Tricks for Parents from Darbi's mom, Kori

Many parents have problems using the foot abduction brace (FAB), which

is also referred to as Dennis Brown Bar (DBB), at first, you are not

alone. Here is some information I have about our experiences with the

DBB and pressure sores (start like a dark/purple spot/bruise).

Blisters also turn into sores - which is why it is very, very

important to get the shoes on right and tight so they don't cause

sores and blisters. Most important is to get the shoes on properly and

do what you have to in order to stop sores from forming. Prevention is

the key here, and if it can't be prevented, you will find information

here how to deal with the problems and get past them while still

wearing the brace. Keep an eye on those feet, and listen to your baby.

Should your child develop a sore or blister, you are not alone and

also not the first parent to have to doctor a sweet babe's foot. We're

here to help you, make sure to post to the list

(http://groups.yahoo.com/group/nosurgery4clubfoot) whenever you need to.

· You may see red spots, and often red is ok - remember, these

tootsies are sensitive in general so expect some redness. Pressure

sores are a different story though and can be recognized by their dark

redness that eventually gets darker and darker till it's purple or

black in color from pressure on the skin. It will become a sore

eventually if the pressure persists. So, if the pressure spots (dark)

get worse or don't go away, something is wrong and it will never get

better till you stop the pressure in that area.

· Blisters (fluid filled – become sores after the skin breaks) are

caused by slipping or friction on a spot on the foot. There must be

absolutely no slipping out of the shoes, even after a few hours. If

they slip eventually, they need to be tighter in the first place.

Remember to flex the foot up, and point the toes up when you put the

shoes on (this is dorsiflexion). The further the heel is placed in the

back of the shoe, and the more dorsiflexed the foot, the tighter you

will be able to get that strap.

· You may not have any problems except for a little fussiness the

first few days that can be relieved with Acetaminophen (i.e. Tylenol)

or Ibuprofen (i.e. Motrin). This is normal for a child who has been

fully corrected and whose feet are securely and deeply seated in the

shoes. Children treated by a Dr. who has fully and properly corrected

the feet do not usually have more than a few days of initial

discomfort. If your child is not tolerating the shoes past the first

few days you should review this document and any others referenced

within to see if there is anything you can do to solve his/her

unhappiness.

If you experience either of the serious problems above you must stop

the slipping or pressure by making sure the boots are on tightly and

the heel seated deep in the bottom of the shoe. Occasionally a baby

will slip out of the shoes and blisters don't form. Don't assume that

because there are no sores or blisters the slipping isn't a problem.

Slipping feet are not held in correction and if it continues, it can

compromise the effectiveness of the brace and lead to relapse. Heels

down and shoes tight are the keys to baby's feet being happy and straight.

I hope this provides some answers to your problems with the new babies

in the DBB. I remember this time very clearly and it was not fun at

all because I was not putting the shoes on properly and my daughter

was miserable and in pain. We learned the hard way, and hope to pass

to others what worked for us best. Most importantly - Listen To Your

Baby!!. S/He will tell you if there is something wrong, and you must

trust your instincts and not make things worse by letting a sore get

worse. You can get past sores, many of us have done it but it is best

to not get them in the first place.

Big Hugs to you parents dealing with this. It will get better!! The

moment we fixed the problem our daughter couldn't have been happier in

the DBB. What a difference! This brace really works!!

Kori

Mama of Darbi

3/28/03

Rt. CF - DBB 12-14hr/day

How to use Markell Tarso Open Toe Boots attached to Bar

FAB/DBB

(Foot Abduction Brace/Dennis Browne Bar)

Most babies will be placed into the standard Foot Abduction Bar that

is commonly referred to the as a Dennis Browne Bar. This brace

consists of a pair of white leather open toe boots specifically

designed to attach to a number of different bars. Some bars are

adjustable in length and some are fixed. There are a few different

designs to attach the shoes to the bar however the two most common use

either a large round bolt or a large round hex head screw. The shoes

are held on with screws attached to sole plates. The shoes have a

strap which is buckled and laces. On the bottom of the bar (gold, red

fixed) and on the sole plates you will see marks which are used to

indicate the degree the brace is set at. Other braces coming into use

are similar in that the feet are connected with some kind of bar but

the design of the shoes, bar or both is a little different. This

document primarily focuses on the standard FAB that uses the

MarkellTaso Open Toe Boot.

Before you put the shoes on the first time:

· Take the laces out and tie a knot in the middle. Then re-lace the

shoes. Tie a knot at the very ends of each lace end so they don't come

out of the holes. This has been a lifesaver for us - we never have to

re-lace them and can pull them very loose to get the shoes on. The

knot in the middle shows us that they're even each time so I never

worry about one side being longer than the other. I love this tip!

· Consider slitting the tongue keeper slit up to the top of the

tongue. This allows the tongue to sit low on the top of the foot - and

allows the top of the boot to be tightened up on the ankle enough so

the fatty baby calf doesn't pull the heel up and out. The tighter the

ankle, the better seated the foot will be. The pictures to the right

show where to cut the tongue keeper slit, where the tongue sits in

relation to the top of the boot un-modified from the mfr., and where

it will sit after you make the slit longer.

· We find it easier to have the straps and buckles on the inside

rather than the outside. Since the feet are pointed out in the first

place, cinching them up on the inside is just easier in general.

Straight Last shoes can be installed on either side of the FAB - as

they are not a right or left shoe. Use a screw driver to switch shoes

if you choose to. The Ponseti Method uses straight last shoes

although sometimes a baby will get reverse last. If you received

reverse last shoes ask about getting the straight last shoes. Reverse

Last is not considered necessary with the Ponseti Method.

· Install the strap in the lower slot on each side of the boot. For

most feet, this is the best position to keep the foot in the shoes.

Some parents switch slots as the child's foot grows. As long as the

foot is staying securely and deeply seated in the shoe either slot is

fine. Remember, whatever works to keep your child's foot in the shoes

is what you should do.

· Medium thickness cotton socks with small seams are recommended. We

like the Old Navy or Gymboree socks with the rubber grips on the

bottom. They are regularly 7 for $10 at Old Navy. I suggest you get at

least 7 if not more. They seem to get lost in the laundry... and it's

not fun trying to find that perfect sock when you need it. Plus you

can make sure you've got the right colors on hand for accessorizing

:~} In the winter after the initial first few months of getting used

to the DBB and worrying about slipping I use tights. Not only for

girls - I put my non-clubfoot boy babies in tights (white, black or

blue of course!) in the winter too - it helps keep their legs warm

when their pants hike up while being carried outside. But tights work

very well with the DBB in our experience. The thicker the better, make

sure they're stretchy so they fit the feet nice and tight. Pull on

any seams which might press into the baby's toes. You may have to use

a different hole when you tighten the strap if you use tights because

they are thinner than socks.

· Remember - when you first get the DBB take it off every 2-3 hours to

check the feet for sores or red marks that don't go away, leaving the

brace on for longer periods of time if baby seems happy is fine. If

baby is showing signs of distress take the shoes off and inspect the

feet. Then use the following instructions and re-install the brace.

You should check the feet often over the first couple of days or more

if baby is showing signs of distress. If you do not see signs that

sores or blisters are forming things are ok - keep the brace on. If

it is warm and humid, you may have to change baby's socks more often

than once per day if their feet are very sweaty.

Installation Tips

(how to put the FAB on a wiggly little baby without causing pain or sores)

1- If you can, take the shoes off the bar when you put them on. If you

have a gold bar this is simple. You may have to use a wrench or pliers

to get it off the first time as some brace shops really tighten them

up. Don't loose the nut. It is best to put the nut back on the shoe

after you take it off the bar – as it helps keep them around and

getting kicked in the thighs without that nut there really hurts! Mark

on the plate where your shoes are to be set at with a Sharpie marker

or another permanent marker. This makes it very easy to put them back

in the right spot - even in low light.

· If you have the red Fillauer adjustable bar it is harder to get the

shoes back on correctly once they're off but not impossible. It is

much easier with two people but still, is more difficult than the gold

bar which uses a nut instead of a screw. To make it easier to get

them correct, mark your bar as shown below (in the circle) before you

take the shoes off with a permanent marker. One parent unscrewed the

clamps and separated the bar (again, a Sharpie mark will help here)

each time she applied the bar but that may wear your clamps out

prematurely. Contacting the manufacturer and having replacement

clamps sent to you in case they break solves this problem or in a

pinch, metal automotive hose clamps will work.

If at all possible, remove the shoes from the bar the first few

weeks/months each time you put them on. You won't have to do this

forever but I really feel it's a better way than trying to put the

shoes on with the bar attached.

Note the black mark pointing to the degree marks on the sole plate

Clips are loosened with an wrench (provided with bar, be gentle!

2- Loosen the laces up all the way to the knots and pull the tongue up

as far as it will go, till the laces reach the ends where the knots

are. If you have short straps, buckle the strap into the last hole

loosely so as not to pull it out when the foot goes in. If this is

still too short and you are *stuffing* the foot into the shoe put an

additional hole in the very end of the strap and use that to keep it

buckled while you put the foot in. These short straps are very

frustrating, but there should be a new/different design on these soon

according to the manufacturer. The longer straps don't need to be buckled.

3- With the shoe off the bar, insert the foot into the shoe and bend

the knee 90 degrees. Push on the top of the knee and hold the sole of

the shoe. Press the heel deeply into the back of the shoe and flex the

toes upward (dorsiflexion) as far as possible. Keep pushing on the

knee and flexing the foot and make SURE the heel is seated well into

the bottom and back of the shoe.

· When applying the shoes while attached to the bar, use these same

procedures but be sure to work one foot at a time and secure it in the

boot tightly before starting on the other side. If the child is

unilateral, start with the clubfoot first. Some parents feel most

comfortable to sit the child on their lap facing away to apply the

brace, others say it's easiest for them to have the baby lying down in

front of them. Many parents work together putting the brace on,

especially at first. Whatever position that works for you best is how

you should do it.

4- With the knee still bent and pressure applied, press with your

thumb or other convenient finger on the strap where it goes through

the tongue keeper slit. Hold the heel into the back of the shoe and

tighten the strap. Buckle it tightly but don't thread the strap

through the lower portion of the buckle just yet. Dorsiflex (point

toes up) the foot again as far as it'll go and press on the knee and

sole of the shoe to make sure the heel is in properly. Re-tighten the

strap very tight, you may get another hole or two tighter. If the

heel is down all the way, you can't tighten it too much. If there is

any wiggle or looseness, press the foot into the shoe again push with

your thumb on the strap and re-tighten the strap again. Center the

tongue and pull it down over the toes. It must be very tight -

tighter than you would imagine it needs to be. So keep going till it's

really tight.

5- Pull the sock at the toes to make sure the seams aren't going to

press into baby's toes - it also helps make sure the heel is seated.

It's ok if they look all bloused out in front. This is good - gives

baby room to wiggle toes and who cares how it looks anyway!

6- Pull the tongue way down over the toes. As far as you can. I prefer

it to sit *under* the top of the boot at the ankle just a little bit.

If it sits too high you may need to cut the tongue keeper slit a

little more. (don't cut it above the stitching)

7- Tighten the laces nice and snug all the way up and tie them. The

shoe should get tighter with the laces being tightened. If you've

been having issues with slipping, try lacing them only to the second

from the top hole and tying them off there.

8- Check to see if the foot can slip out of the boot at all. If it

moves it'll loosen up with time and slip again. If it's not tight,

repeat the above instructions with emphasis on the pressure on the

knee and pushing the heel into the bottom of the shoe with the foot

flexed up (toes pointing toward the baby's head) all at the same time.

This isn't easy at first, but you will get used to it and very good at

it in short time.

9- Repeat the procedure with the other boot.

10- When both boots are on - take the nuts off and put the bar back

on. If your baby is bilateral it doesn't matter which side you do

first. If baby is unilateral it's easier to put the clubfoot side on

first as the other side set at 45 degrees or less is easier to put on

the bar second. If you are applying the brace with the shoes

attached, it is also much easier to start with the clubfoot first.

Signs of Trouble

· Baby cries a very unnatural (for your baby) unhappy in pain cry all

the time, kicks legs violently like she's trying to kick the shoes

off, wakes at night every half hour or less (other than being hungry),

purple/black marks on the heels or other parts of the foot, blisters

form or sores form..

· All these are typically caused by the shoes not being on properly.

If pressure sores or blisters appear - you MUST fix whatever is

causing the problem before you put the shoes back on. Sores will not

heal in the shoes once they appear (skin falls off and actual sore is

resident - as opposed to just a purple or black mark). It might mean a

trip back to the Dr. for a healing cast. Which is ok - it keeps the

correction while the sore heals. You MUST find out why the sore came -

if it's slipping or pressure or whatever - find it and fix it. When

you go back to the DBB follow the above directions and make SURE the

heels are down 100% in the bottom of the shoes. Blisters are caused by

friction, or rather slippage. Slippage is often caused by the strap

not being tight enough. It may seem tight enough, but if slippage

happens it very likely is not tight enough. If the heel is rising up

it seems tight but once you get the heel down you'll find you can

tighten it up another couple of holes. Dorsiflexing the foot while you

put the shoes on really helps prevent this.

· After having persistent sores some parents have resorted to actually

cutting a large hole in the heels of the shoes. This helps to relieve

pressure so that baby can continue to wear the DBB while a sore heals.

It is not a long term fix. The foot must be in the shoe properly for

long term wear. However, after cutting the hole many parents have

found that they were not getting the heel down all the way and were

then able to see to make sure the heel is down. I don't recommend this

for everyone - it is a short term bandaid to the larger problem of

proper fitting of the shoes. However it is a good option to going back

to casts for healing and starting again with the 23/7 schedule for

wearing the FAB. It also is often the only way we realize that the

heel is not seated properly so if you can't otherwise figure out why

the baby is upset, cut the hole and take a peek inside. The shoes

will not fall apart and are essentially disposable as they can only be

worn for a few months till baby needs a larger size. For more

information about this you can contact me personally -and I can help

you find a solution to healing your child's sores. We have endured

this and hope to not see any other babies have to go through this pain

and unhappiness. Remember - there is a light at the end of the tunnel

and you can find a way to keep the FAB on so your baby can take

advantage of the most effective brace to complete the non-surgical

treatment.

o Markell has released a new shoe design that comes with this hole

already cut. These shoes are available in the smaller sizes, 0000,

000, 00, 0, and 1. They can be specially ordered from Markell, ask

your Orthotist to contact Markell Shoe Company if you would like

these. www.markellshoe.com/

Other reasons why baby may be uncomfortable are:

· Muscle tenderness and skin sensitivity right after casts are taken

off. This is unfortunate, but will get better with time. Don't rub the

legs - this hurts more. A little lotion is ok but keep it off the feet

itself as it can cause slipping. If your baby has skin sensitivity,

use a firm touch when handling the legs and feet as a gentle touch can

be very irritating to the child.

· Bar is too long or too short. The heels of the shoes (fixed on the

bar in the correct positions – 70° for a clubfoot and 20-45° for non

clubfoot) should be shoulder width apart. Any less or more is

uncomfortable for baby. It is not the length of the bar - it is the

distance between the heels. Take the brace and place it up to baby's

shoulders to check this.

· Foot is at the wrong position. The clubfoot should be at 70 degrees

or *AT LEAST* as far turned out as the last cast. Parents - save your

last cast. Take that cast and put it up to a protractor with the knee

pointed to 0° and see where the midline of the foot portion points to.

Then set your DBB. If it is much less than 60° consider talking to

your doctor about another cast and proper abduction. The last cast in

the Ponseti Method should be at 70°. If your cast is not abducted to

this degree, and your doc doesn't see fit to re-cast, you can try to

get there slowly over time however it may not work and this is a red

flag that your doctor is modifying the Method and it could be cause

for relapse and subsequent surgeries. If you think you need a second

opinion to check your child's correction, by all means go get it. If

you wish to try to move up to 70 degrees, set your brace to where the

cast is set at and slowly, once a week increase it by 5 degrees. Do

not abduct the foot further out than the last cast right away as this

causes considerable discomfort for the baby.

· Baby is irritated by not being able to move legs independently. You

can show baby how to move his legs together, gently. Don't move those

legs around too much, they have just come out of casts and the muscles

will be very sensitive. They might not like this at first but will

soon learn to lift their legs up with the brace on. A very small baby

may not really care about moving his/her legs much, so you only need

to show them this every once in a while if they seem upset about it.

This is actually a minor irritation for the baby. They get used to

this fairly quickly and the younger they are the less you will need to

*show* them this, they'll figure it ALL out soon enough. Amazing

little ones they are!

· It is very important to NOT take baby out of the brace unless

absolutely necessary. Do everything you can to make sure your baby

stays in the brace. However remember to listen to your child and

follow your heart. If you see signs of sores there is a problem you

need to tackle and rectify. Do NOT keep a brace on a child who has a

weeping sore. This is painful and you wouldn't put a tight shoe on

your own foot with a sore like that. If your child is telling you

she's in pain she likely is and you need to find out why. Do what you

can to keep the brace on - but don't make a bad situation worse by

putting it on incorrectly and causing sores. See your Dr. about

healing casts or cut a hole... but don't make sores worse.

· If your baby is irritable at first consider co-sleeping so everyone

gets some sleep the first few nights. You can side lie and nurse a

baby wearing the dbb, it's a little different than a baby who doesn't

wear one but is absolutely doable. Even if you only do this for a few

days while baby is getting used to the brace - it will help everyone

in your family get sleep the first few nights. Put a pillow under

baby's feet. It is easy enough for baby to side lie in the DBB with a

pillow under his/her feet.

· Good luck and don't forget to post to the list if you need help.

We're here for you and have lots of different takes on how to make the

shoes and bar work so there's lots of different ways to work through

problems.

June 3, 2005