Head-splitting fractures which involve both articular surface and tuberosities often have a significant portion of the head that remains with the greater tuberosity. They need to be properly reduced to achieve good results in terms of stability, function and pain relief. It is especially necessary to reduce any intraarticular gap or step-off. Typically, there is a double profile image of the head on an appropriately oriented x-ray, but the split in the humeral head articular surface is hidden inside the joint capsule, under the rotator cuff.
Operative fixation is the preferred treatment. However, the decision for surgery should also include the functional demands of the patients, the presence of comorbidities, and the ability to undergo operative treatment.
Indications for arthroplasty are inability to achieve satisfactory reduction and stable fixation, especially in elderly patients with osteoporotic bone.
Given the articular surface deformity and varus malalignment, nonoperative treatment is likely to be followed by limited functional outcome and increased pain.