Nonunion of tibial stress fracture has been reported in athletes and only in proximal and midshaft of tibia. We have found no report of nonunion of a stress fracture in distal tibiofibula. Report of this lesion, especially in a non-athlete adolescent, is interesting and important.

Objective: Nonunion fracture of lower-extremity long bones is really important because these bones bear the weight of the body. Some reasons of nonunion fracture are: Instability and immobility of the fractured fragments; insufficient blood supply to the fractured site; and damage to periosteum and necrosis of periosteal cells caused by insufficient blood supply. There are two methods of nonunion treatment based on Iranian traditional medicine: (A) Nonsurgical treatment including physiotherapy, ultrasonic or electromagnetic waves or injection of Maltose-binding protein for stimulation of bone regeneration; and (b) Surgical treatment with the aim of fixing fractured parts internally and externally, and eventually bone graft in the form of allografts and autografts. Methods: The patient was a 29-year-old man whose thigh bone had been fractured in an accident at the age of 21. During 8 years, he had underwent surgical and nonsurgical treatments as well as allograft and autograft transplantation, but unfortunately none of these treatments were effective and he suffered from infection, transplant rejection and necrosis of fractured fragments. Disappointed patient was subjected to treatment based on traditional medicine including modification of lifestyle and dietary regime, and using traditional drugs and leech therapy. Conclusion: After 6 months of therapy, avascular necrosis was completely removed and new bones were created in the areas between the fractures and the patient got better over time. By expanding education and research in the field of Iranian traditional medicine, we can increase the use of effective, noninvasive and low-cost Iranian-based therapies which have great role in improving the quality of life of the individual and community and can prevent from expensive material and spiritual costs of surgery and amputation.

Background and purpose: Nonunion of bone fracture is a clinical and treatment challenge. Satisfactory repair of orthopedic fractures is of great importance and systemic treatment is used to achieve this goal. This study aimed to investigate the effect of Teriparatide (CinnoPar® ) on nonunion fractures. Materials and methods: A quasi-experimental study was conducted in 17 patients with nonunion bone fractures. Radiographic evaluation was performed before the intervention and nonunion was confirmed by a radiologist. Then, all patients received Teriparatide for three months. Afterwards, a control x-ray image was taken to assess the outcome. Results: Sixteen patients (mean age: 45. 18± 20. 51) with nonunion fracture were evaluated, including nine males and seven females. The mean time after the accident was 50 ± 24. 48 weeks. Femoral bone was the most reported impaired site (n=8). After treatment with Teriparatide (CinnoPar® ) improvements were seen in 10 patients (P= 0. 002). Conclusion: Treatment with CinnoPar® was found to be effective to some extent. However, due to the small sample size in this study, the efficacy of CinnoPar® needs further assessments.

Non-union is a complication in the management of patients who have a fracture of the tibia. The records of twenty patients who were treated by intramedullary nailing with reaming for non union of the tibia were reviewed.The fractures had been treated initially by closed reduction and immobilization in a cast, external fixation, fixation by pins in a plaster cast and dynamic compression plating. After the initial treatment had failed, intramedullary nailing with reaming was done to gain union. By usinse the standard operation table, the knee was flexed 90 to 100 degrees. Make an incision Middle to the patellar tendon using the awl opening the medullary canal proximal to the tibial tuberosity, the site of the non union was opened. Bone graft used in all patients and a fibular osteotomy was done. Union occurred in the average time of 7.9 months.The average time from the diagnosis of non union was 10.1 months in %95 of cases. Tibial union occurred in all cases. Complication included fracture of the Nail in one case, which necessitated an additional casting and union occurred finally.

Background: Scaphoid is the most common carpal bone to fracture, and non-union is the most common complication of scaphoid fracture. The vascularized bone grafting, based on pronator quadratus muscle for scaphoid non-union is an option for a more successful union. We would like to report our experience. Methods: In a descriptive study between 2003 and 2004, 11 patients with scaphoid nonunion were operated on with pronator quadratus vascularized bone graft. The mean age of the patients was 22.9 years (18-29) and the duration of non-union was 12.2 months (6-24). The patients were evaluated clinically and radiographically after 6 months. Results: Union was achieved in 10 out of 11 patients. The mean time to union was 12 weeks. The mean pain score in the patients with union was 3.8 before and 1 after surgery. Seven patients had no activity related pain and 3 others experienced minimal exertional pain. There was no instance of fixation failure or substantial loss of reduction. The mean final range of motion of the wrist was 19° extension, 15° flexion, 5° radial deviation and 10° ulnar deviation. Final assessment of pain relief, improved motion and increased wrist function was excellent in 5 patients, good in 3 and fair in 2 patients.Conclusions: Pronator quadratus vascularized bone graft is an effective method for treatment of scaphoid nonunion, leading to rapid union and good wrist function, although it is a bigger surgery and takes longer to perform.

Background and purpose: One of the most important complications of bone fractures is nonunion. This research aimed at comparing the effect of exchange nailing and plate augmentation on complications after surgery and the time to achieve desired outcomes. Materials and methods: This descriptive-analytical study was conducted in 12 femoral shaft nonunion cases treated operatively in 2011-2018 (eight patients were managed with plate augmentation and four patients were treated with exchange nailing). Demographic characteristics of the patients, type of fracture and type of surgery were recorded. A year after the surgery, anteroposterior and lateral view profiles were prepared from all patients and the extent of bone fusion was evaluated by orthopedic surgen. Results: Four patients (33. 33%) underwent intraosseous nail replacement surgery and eight (66. 67%) underwent plate augmentation surgery. Two patients (16. 67%) developed infections and five (41. 67%) had a short limb complication. The average limb shortness in these patients was 1. 10± 0. 22 cm. The average duration of union after discharge was lower in patients with plate augmentation than those with replacement of the intramedullary nail. Conclusion: In current study, faster uninon achieved, so, augmentation plating could be a good choice in patients with femoral shaft nonunion.

Background and purpose: External fixation is currently considered as a standard treatment for open tibial fractures; however, due to the long-term hospitalization and some other complications, some researchers have proposed intramedullary nailing as the alternative surgical treatment. This study was conducted to compare the treatment of open tibial shaft fractures by external fixation and intramedullary nailing.Materials and methods: This randomized controlled clinical trial was conducted on 113 patients with open tibial fractures type I and II (Gustilo classification) during a two year period. These patients were divided in two groups and 59 cases were operated using external fixation and 54 fractures were fixed with intramedullary nailing. The patients were compared for complications such as union time, delay in the union, nonunion and infection.Results: One hundred and thirteen patients (95 males and 18 females) with the age range of 18-50 years (average age: 34.3) were enrolled in this study. Among the 59 patients treated with external fixator, 8 had delayed union. Three of these eight patients suffered from the nonunion and did not have any progress in callus formation till 6 months after the treatment. On the other hand, among the patients (54 cases) treated with intramedullary nailing, 2 cases suffered from the delayed union and one had nonunion. The difference between the two methods of treatment in delayed union and nonunion situation was not statistically significant (P>0.05).Conclusion: Due to the reduced hospital stay in intramedullary method and the necessity of doing repeated surgery and applying intramedullary nailing when the patients are not treated with external fixation, the researchers recommend intramedullary nailing as the first option in treating such patients.