scapular spine stress fractures are uncommon following cuff tear arthropathy , there are only six reported cases in the english literature .
management of these fractures remains a challenge because of poor bone quality and persistent deforming force at the fracture site .
management of these fractures can be conservative or surgical , with good functional outcome being associated with fracture union .
conservative management can lead to asymptomatic nonunion , and there is a risk of recurrence of symptoms leading to a painful stiff shoulder .
we present a case of bilateral scapular spine stress fractures that was treated operatively on one side and conservatively on the other with satisfactory functional outcome , besides we reviewed the literature to find the optimal treatment option .
a 61-year - old right - hand dominant gentleman was referred to our clinic with sudden deterioration bilateral shoulder pain and loss of function . he was a retired ambulance driver with long - standing and established bilateral massive rotator cuff tear and arthropathy ( worse on the left ) .
clinically , he had very limited and painful , active movements bilaterally ( 30 of abduction and forward flexion , no external rotation and internal rotation to sacrum ) .
he was tender over both scapular spines , with significant site mobility and pain on the left side .
shoulder radiographs , computed tomography ( ct ) and magnetic resonance imaging ( mri ) revealed chronic bilateral massive rotator cuff tears with significant retraction of the supraspinatus and infraspinatus associated with fatty infiltration .
there was associated superior migration of the humeral head on both sides with the loss of acromio - humeral space .
bilateral stress fractures of the spine of scapula were noted with the left side being significantly displaced with no evidence of healing [ figure 1 ] .
the patient had a history of chronic obstructive pulmonary disease ( copd ) and suffered from noninsulin - dependent diabetic mellitus . computed tomography reconstruction on initial presentation showing bilateral scapula spine fractures .
note the left side is grossly displaced compared to the right although , he initially had severe pain in both shoulders , symptoms in his right shoulder reduced with conservative treatment after 2 months , with diminishing pain and functional improvement .
this was further confirmed with x - rays and ct scans showing callus formation and progression to union [ figure 2 ] .
however , his left side remained symptomatic with pain , abnormal mobility at the fracture site , and no radiological evidence of healing [ figure 3 ] .
the patient underwent a successful open reduction and internal fixation of the left scapular spine with 3.5 mm limited contact dynamic compression plate ( synthes ) and iliac crest bone grafting .
postoperatively the arm was immobilized in a polysling allowing rotational movements and pendulum exercises for 4 weeks .
this was followed by active assisted forward flexion and abduction to 90 for further 2 weeks and a full range of movement exercises as tolerated by the patient after 6 weeks .
the fracture progressed to union uneventfully with significant improvement in symptoms and function in his left shoulder [ figure 4 ] .
as the patient 's symptoms improved , he refused further treatment and arthroplasty for his cuff tear arthropathy as his level of symptoms were manageable . at the final follow - up at 2 years
, the patient was asymptomatic with regards to the scapular spine fractures with reasonably good function [ table 1 ] .
his oxford shoulder score ( oss ) was 30 for both shoulders and disabilities of the arm , shoulder and hand ( dash ) score was 30.8 at the final follow - up .
radiograph ( left ) and computed tomography scan ( right ) of the right shoulder after conservative treatment showing evidence of callus formation and healing .
this correlated well with clinical symptoms of reducing pain and improving function radiograph ( top left ) , magnetic resonance imaging ( top right ) and computed tomography ( bottom ) of the left shoulder showing evidence of nonunion of the scapula spine fracture , this correlated with persistent symptoms of pain and increased mobility at the fracture site follow - up computed tomography scan of the left shoulder at 2 years after open reduction and internal fixation with plates and screws showing bony union
massive rotator cuff tears alter the kinematics of the gleno - humeral articulation . in patients with massive cuff tears ,
the humeral head comes into contact with the overlying acromion during movements in the arm .
this may lead to antero - superior migration of the humeral head and altered bio - mechanics . during shoulder movements ,
the elevated humeral head transfers increased loads across the acromion , and the spine of scapula . over time
, these abnormal forces on the acromion could lead to remodeling of the acromion and spine of scapula according to wolfe 's law with acetabularization of the acromion .
however , in patients with other predisposing factors such as osteopenia in our patient and other patients reported in the literature , the risk of stress fractures increases because of the reduced remodeling potential .
copd can be a mechanical factor , where chronic cough produces repetitive micro - trauma to an already weakened bone . in our case ,
steroid use , chronic cough , and osteopenia secondary to long - standing copd in addition to long - standing cuff tear arthropathy likely led to the stress fractures .
a medline search was conducted to find all articles on scapular spine stress fractures from 1966 to march 2013 [ table 2 ] .
groot et al . , treated two such patients with physiotherapy , analgesics and ultrasound bone growth stimulation , however , the fractures did not unite , and the patients ended up with painful stiff shoulders [ table 2 ] .
interestingly , one of their patients whose symptoms settled initially presented after 10 months with recurrence of severe pain .
this raises doubts about leaving the asymptomatic nonunion without treatment , as it can lead to further disability in an already compromised shoulder .
shindle et al . , in his study tried conservative treatment in two patients and eventually ended up operating on both . in one patient where the fracture was fixed with plates and screws , the fracture united and the patient regained painless shoulder elevation despite cuff deficiency at 3 months . in the second patient , the scapula fracture failed to progress to union with conservative management but was minimally displaced .
her pain was not thought to be due to a fracture , so a reverse total shoulder arthroplasty was performed , however , the patient developed postoperative infection and died .
biomechanically , reverse total shoulder arthroplasty reverses the forces responsible for stress fractures of acromion and scapular spine in cuff tear arthropathy , however increased tension , and elongated deltoid can potentially worsen the situation by increasing the stress in acromion and scapular spine in the opposite direction . in patients with scapular spine stress fracture following reverse total shoulder arthroplasty ,
operative fixation is the treatment of choice , as poor functional results were associated with conservative treatment .
roy et al , treated a patient with minimal symptoms from a scapular spine stress fracture conservatively .
the patient was wheelchair - bound and was admitted in a medical ward for heart failure and chronic varicose ulcers . at 6 months
the outcome scores measured at the final follow - up did not accurately reflect his recovery from the scapular spine stress fractures .
some components of the score , such as household chores and shopping and recreational activities , were limited because of his severe copd rather than his shoulder problems .
however , the oss and dash scores were equal at final follow - up for both shoulders highlighting the fact that the fracture union is essential to regain prefracture levels of function . based on present literature review , union following symptomatic scapular spine stress fracture
is associated with good functional outcome . however , even in patients with painless nonunion , there is a risk of recurrence of symptoms that may result in a painful stiff shoulder .
if conservative treatment fails , operative treatment can be considered if the shoulder remains symptomatic .
scapular spine stress fractures are rare , but can occur in patients with a combination of massive rotator cuff tear with arthropathy and poor bone quality .
fracture union either by conservative or operative route is associated with a good functional outcome and is supported by our literature review .
 we report a case of bilateral scapular spine stress fracture , treated conservatively on one side and operatively on the other side . besides , we performed a literature review to establish management options . 
 a 61-year - old right - handed gentleman came to our clinic with acute on chronic deterioration of shoulder pain and loss of arm function . clinical assessment and investigations revealed long - standing bilateral rotator cuff tear and scapular spine stress fractures . 
 the fracture on the right side united with conservative management for 2 months . 
 however , his left side remained symptomatic with pain , abnormal mobility and no radiological evidence of union . 
 the fracture progressed to union after fixation and bone grafting . at the final follow - up at 2 years 
 , the patient was asymptomatic with regards to the fractures with oxford shoulder score ( oss)-30 and disabilities of the arm , shoulder and hand ( dash)-30.8 . 
 fracture union either by conservative or operative treatment is associated with good functional outcome and is supported by our review . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION