PubMed 2. Using the Details function - Head Splitting Fractures of the Shoulder

This is the second in a series of mini-workshops on the subject of using PubMed. It focuses on the use of the "Details" function to work out what is happening with your search. We will use the example of  head splitting fractures of the shoulder. Because of the size of some of the illustrations it might be a good idea to maximize the viewing window.

When you submit a search request the PubMed robot analyses your search string (the words you type in) in a complex way.

• it checks the syntax to see if you have used quotes, parentheses, or Boolean operators such as AND OR NOT. These have to be in capitals to be recognized as such
• it looks to see if you have specified any words as pertaining specifically to the title, the authors, journal or text
• it checks if any terms you have used belong to the special vocabulary of the NLM - Medical Subject Headings or MeSH terms. If they are or if they are "entry terms" - common synonyms of MeSH terms - that term will be added to the search string and specified as a MeSH term.
• if you have not used Boolean logic terms it supplies them. The default assumed if you leave a space between terms is AND.

Although this is meant to be helpful, and usually is, the translation of your request can significantly distort the intent of your search, leaving you baffled about why the search did not turn out as you expected.

When this happens and you are not sure why (eg spelling has been checked), the best plan is to use the Details function to see how your search request was interpreted.

Open PubMed and enter the search string head splitting fracture of the shoulder

This actually works quite well with a reasonably small number of citations (19) most of which are on subject. To investigate the translation of the search click on the details tab just below the search string box. (you have to do this after you have run the search not before).

I would substitute the word translated for the word "enhanced"!
Part of the Details page is reproduced below. It consists of 6 sections in reverse logical order - the original query is last and the resulting translation is first. The sections are

1. Query Translation - this is the final search string the robot actually used in the search
2. Result - the number of article found by the search. The number is a link to the actual search
3. Stopwords Ignored - common words including and, or, not, the, of and all numbers are usually ignored. If you want them in the search string enclose them in quotes. If you want Boolean operators use upper case
4. Translations - these show how the individual terms of your search string are translated. If a term is translated as a MeSH term then all articles which the librarians classified as being about that subject, will be "caught".
5. Database - the database searched (usually PubMed)
6. User query - the search string you entered

Conclusion: this translation is quite good but not right on target. The MeSH term "Head" is certainly not needed and the term "shoulder" may be a bit inexact. If the article was entitled "Intra-articular Fractures of the Proximal Humerus" it would not be picked up. The sensitivity of the search is completely dependent on the term "splitting". If you delete that term you get nearly 450 articles

When words are used inside quotes they have to appear exactly in that form in the article. It seems that - is considered the same as a space. If we use the term "head splitting" or "head-splitting" you get the same results. If you compare this collection with the original search we find that 3 articles (Brits, naturally) used the words "splitting of the humeral head". Consequently these article did not turn up in the search for "head splitting" in quotes which required the exact phrase but did turn up in the search for head splitting which simply requires that both words be somewhere in the article. It is precisely this type of fiddly detail which make PubMed searching unpredictable and which makes the details function a major help.

Summary

1. When a search has not produced the expected results the details function should be employed
2. By elucidating the way in which the query was translated it is often possible to improve the search

Further Study

Copy the search string Intertrochanteric Fractures of the Hip exactly into the PubMed Search engine and run the search. Use the Details function to explain why this search produces such unexpected results.

Comments to the Orthopod Mailing List. Please don't forget to edit out the end of this message if you reply.

Other workshops in this series

• Index
• Basic PubMed (Calcaneo-navicular Bar)
• Using the Details Function (Head Splitting Fracture of the Shoulder)
• Display Controls (Infected non-union of the Tibia)

Myles Clough  mylesclough@shaw.ca

Abstracts of the relevant papers found by this search

1: Am J Orthop. 2003 Jul;32(7):349-52. 
The management of anterior dislocation of the shoulder with proximal humerus
fracture, bony Bankart lesion, and associated glenoid labrum avulsion: a report
of 2 cases.
Lahav A, Rogachefsky R, Toledano B, Meinhard BP.
State University of New York at Stony Brook Medical Center, Stony Brook, New
York, USA.
Proximal humerus fractures are common in the older population. These fractures
can be associated with dislocation of the shoulder. Four-part
fracture-dislocations and head-splitting 3-part fractures are generally
indicated for shoulder hemiarthroplasty in the older population. When such
surgery is warranted, inspection of the glenoid during the procedure is
indicated, as loss of evaluation may lead to postoperative shoulder instability.
There is value in alerting orthopedic surgeons to the possibility of anterior
glenoid rim fracture in association with proximal shoulder fracture-dislocation.
We focus on this issue and advise that the lesion can be visualized and
confirmed at open reconstruction and does not need multiple radiographic views.
Publication Types:
    Case Reports
PMID: 12892280 [PubMed - indexed for MEDLINE]
2: Orthopade. 2001 Jun;30(6):386-94. 
[Shoulder hemi-arthroplasty in proximal humeral fractures]
[Article in German]
Heers G, Torchia ME.
Orthopadische Universitatsklinik Regensburg, Kaiser-Karl-V. Allee 3, 93077 Bad
Abbach. guido.heers@klinik.uni-regensburg.de
Most fractures of the proximal humerus with significant displacement are best
treated surgically. The range of surgical treatment varies from closed reduction
and pinning to hemiarthroplasty depending on the degree of displacement, age of
the patient, and bone quality. Determining whether or not the individual
fractured bone segments are displaced to a significant degree requires high
quality x-rays which can be difficult to obtain from acutely injured patients.
Indications for replacement of the humeral head in acute fractures include: head
splitting fractures in elderly patients, Neer 4-part fracture dislocations,
selected 3 part fractures and fracture dislocations in elderly patients with
poor bone quality and a very small head fragment, selected severe impression
fractures in elderly patients that involve more than 40% to 50% of the articular
surface and selected anatomical neck fractures in which internal fixation is not
possible. If a prosthetic replacement of the humeral head is chosen, secure
repair of the tuberosities is essential to avoid tuberosity migration and
malunion. The clinical results of prosthetic replacement of the proximal humerus
for acute fractures are superior to those for late arthroplasty. This treatment
modality has been proven to relieve pain. However, even for patients treated
with primary arthroplasty, a restricted range of motion has to be expected
postoperatively. Furthermore, several studies indicate that a significant number
of complications can occur following early and late prosthetic replacement.
Humeral head replacement as a salvage procedure after malunions or failed open
reduction and internal fixation is technically demanding with a relatively high
rate of complications. Newer implant designs and instruments may improve the
clinical results.
Publication Types:
    Review
    Review, Tutorial
PMID: 11480091 [PubMed - indexed for MEDLINE]
3: Orthopade. 2000 Apr;29(4):327-41. 
[Proximal and distal humerus fractures in advanced age]
[Article in German]
Lill H, Josten C.
Klinik fur Unfall- und Wiederherstellungschirurgie, Universitat Leipzig.
In contrast to distal humeral fractures, humeral head fractures represent a
common injury to the old patient. For both fracture localizations osteoporosis
and multi-morbidity are of significant importance. The classification for
humeral head fractures in one-, two-, three- and four-part fractures is
generally accepted. Valgus impacted head fractures as well as head-splitting
fractures are considered a separate entity. In none or minimally displaced
fractures good functional results are achieved by conservative means. Although
numerous therapeutical procedure are offered in the treatment of displaced
fractures of the proximal humerus the result are often disappointing. Generally,
minimal invasive surgical procedures should be preferred. However, in dislocated
multi-part fractures a primary humeral head replacement is often the treatment
of choice. In patients with multifarious morbidity a conservative treatment is
always to be included into the therapeutical considerations. Distal fractures of
the humerus are classified into extraarticular, intraarticular uni-condylar and
intraarticular bi-condylar fractures. The therapeutical recommendations, also in
the elderly, is relatively homogeneous: primary open reduction and internal
fixation (ORIF) should be carried out aiming for an early postoperative
functional treatment. Depending from soft tissue conditions and accompanying
injuries the functional results are often good or moderate and are generally
comparable to those of younger patients. Following a correct indication for
surgical intervention the main priority for both distal and proximal humeral
fractures is an early definitive surgical treatment.
Publication Types:
    Review
    Review, Tutorial
PMID: 10851693 [PubMed - indexed for MEDLINE]
4: Orthop Clin North Am. 2000 Jan;31(1):51-61. 
Management of surgical neck nonunions.
Galatz LM, Iannotti JP.
Shoulder and Elbow Service, Department of Orthopaedic Surgery, Washington
University School of Medicine, St. Louis, Missouri, USA.
A surgical neck nonunion is a seriously debilitating complication of a proximal
humerus fracture. Patients have virtually no functional use of their shoulders
and experience pain. Successful treatment is reliable in relief of pain and
potentially can restore function. The diagnosis is not difficult, however, a CT
scan may be necessary to identify tuberosity or head-splitting fractures.
Successful treatment for these nonunions is difficult but gratifying because the
percent improvement is immense.
Publication Types:
    Review
PMID: 10629332 [PubMed - indexed for MEDLINE]
5: Orthop Clin North Am. 1998 Jul;29(3):467-75. 
Shoulder hemiarthroplasty for proximal humeral fractures.
Hartsock LA, Estes WJ, Murray CA, Friedman RJ.
Department of Orthopaedic Surgery, Medical University of South Carolina,
Charleston, USA.
Shoulder hemiarthroplasty is a well-accepted surgical procedure for the
treatment of specific subtypes of proximal humeral fractures, including
four-part fractures, three-part fractures associated with severe osteopenia,
head-splitting and severe articular impression fractures. Careful patient
assessment and meticulous surgical technique are essential to prevent
complications. The results are satisfactory in approximately 80% of cases. The
results are better in younger patients and in acute versus chronic fractures.
There are a significant number of complications that are related to technical
details of the procedure. Careful placement of the prosthesis and secure
reattachment of the tuberosities to the shaft reduce the chance of complication
following surgery. Good to excellent results in terms of range of motion and
pain relief can be expected in most patients.
Publication Types:
    Review
    Review, Tutorial
PMID: 9706293 [PubMed - indexed for MEDLINE]
6: Clin Orthop Relat Res. 1996 Jun;(327):225-37. 
Surgical treatment of complex fracture of the proximal humerus.
Ko JY, Yamamoto R.
Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Kaohsiung,
Kaohsiung, Taiwan.
Sixteen patients aged 19 to 63 years (average, 52 years) were observed from 1.8
to 5.6 years (average, 3.8 years) after open reduction and internal fixation
with or without external fixation of 3- and 4-part displaced fractures of the
proximal humerus. There were 12, 3-part displaced greater tuberosity and
surgical neck fractures with 6 concomitant dislocations. Four cases were 4-part
fractures with 3 concomitant dislocations. Fixation was achieved with heavy
sutures or wire that incorporated the rotator cuff tendon, tuberosities, and
shaft combined with threaded pins or Hoffmann external fixation to enhanced
stability for early rehabilitation. According to Neer's criteria, 14 (87%) of
the 16 patients had satisfactory or excellent results. Two (13%) of the 16 had
unsatisfactory results. The use of a technique of limited soft tissue dissection
and internal fixation with or without external fixation achieved good fracture
stability and a high percentage of satisfactory results. The limitations of the
procedure include (1) patients who could not tolerate anesthesia, (2) complex
displaced fractures in older patients with osteoporotic bone that cannot hold
pins or external fixation, (3) older patients with 4-part fracture dislocations
in which avascular necrosis of the humeral head occurs frequently and in which a
subsequent endoprosthesis insertion is inappropriate if osteosynthesis fails,
and (4) head splitting fractures. The described approach provides an alternative
method for the treatment of complex displaced fractures of the proximal humerus.
PMID: 8641068 [PubMed - indexed for MEDLINE]
7: J Bone Joint Surg Am. 1992 Jul;74(6):884-9. 
Modular hemiarthroplasty for fractures of the proximal part of the humerus.
Moeckel BH, Dines DM, Warren RF, Altchek DW.
Shoulder Service, Hospital for Special Surgery, New York City, N.Y. 10021.
A new biomodular prosthesis was used for the treatment of a displaced fracture
of the proximal part of the humerus in twenty-two shoulders in twenty-two
patients. The fractures were classified according to the Neer system; there were
thirteen four-part, five three-part, and four head-splitting fractures. There
were fifteen women and seven men, and the mean age was seventy years (range,
forty-nine to eighty-seven years). The hemiarthroplasty was performed an average
of eleven days (range, one to forty-five days) after the injury. The
deltopectoral interval was used in all patients, and the prosthesis was
implanted with cement in twenty of the shoulders. All of the patients
participated in a supervised program of rehabilitation. The patients were
followed for an average of thirty-six months (range, twenty-six to forty-nine
months). Twenty of the twenty-two patients had a good or excellent result. The
active forward elevation averaged 119 degrees; external rotation, 40 degrees;
and internal rotation, to the twelfth thoracic vertebra. All of the patients
except for the two who had a poor result had satisfactory relief of pain. The
two patients who had a poor result had a successful revision with a modular
prosthesis of the same design. The modular head could be removed, enabling the
surgeon to gain access to the glenoid and to adjust the soft tissues. The
over-all scores correlated inversely with the age of the patients and the
interval from the injury to the operation.(ABSTRACT TRUNCATED AT 250 WORDS)
PMID: 1634578 [PubMed - indexed for MEDLINE]
8: Langenbecks Arch Chir. 1990;375(4):225-30. 
[Humerus head resection as therapy of compound fracture of the upper
arm--results]
[Article in German]
Skruodies B, Wening JV, Jungbluth KH.
Abteilung fur Unfallchirurgie, Chirurgische Universitatsklinik
Hamburg-Eppendorf.
Proximal humeral fractures are frequent injuries in older patients. Most of
these fractures respond satisfactorily to conservative treatment. Problems arise
in cases of four-part displacements and in head-splitting fractures with massive
defects in the articular surface. Between 1970 to 1988 eight patients were
treated in our clinic in this situation by resection of the humeral head. 6
patients could be followed-up for an average of 69 months. Postoperative
findings showed a restricted range of motion in all operated shoulders. The
average abduction of the arm was 60 degrees (40-80 degrees) and elevation 60
degrees (40-80 degrees). The patients showed a mean external rotation of 17
degrees (5-30 degrees) and an internal rotation of 48 degrees (5-90 degrees).
Only one patient was painless, 2 patients had pain during the night, and 3
patients suffered from various pain symptoms. Nevertheless 5 of 6 patients
assessed the result as satisfactory and one patient as good.
Publication Types:
    Case Reports
PMID: 2395390 [PubMed - indexed for MEDLINE]
9: Injury. 1989 Jul;20(4):195-9. 
Treatment of displaced fractures of the proximal humerus: transcutaneous
reduction and Hoffmann's external fixation.
Kristiansen B.
Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen,
Denmark.
Experience with transcutaneous reduction and external fixation of displaced
fractures of the proximal humerus is presented in a series of 28 cases followed
for 1 year or more. In 18 cases near-anatomical fracture reduction was obtained,
while no improvement of fracture position was seen in two cases. Loosening of
the pins was a major complication in five cases, all in patients with severe
osteoporosis or head splitting fractures, where fracture reduction was
unsatisfactory. The functional results were satisfactory, and the method is
considered a useful alternative in the treatment of these difficult fractures.
PMID: 2592091 [PubMed - indexed for MEDLINE]
10: Unfallchirurgie. 1985 Aug;11(4):215-8. 
[Humeral head fractures following epileptic attacks. Case report on a rare but
typical injury]
[Article in German]
Siebler G, Lausen M.
We report about two patients with posterior fracture-dislocation of the shoulder
following convulsive seizures, one case unilateral, one case bilateral. The
radiological findings are typical and similar to the cases described in
literature: Impression or head splitting fracture of the ventro-medial part of
the humeral head associated with posterior dislocation. The mechanism of injury,
methods of treatment and late results are discussed.
Publication Types:
    Case Reports
PMID: 4049575 [PubMed - indexed for MEDLINE]
11: J Bone Joint Surg Br. 2002 Sep;84(7):1084; author reply 1084-5. 
Comment on:
    J Bone Joint Surg Br. 2001 Apr;83(3):423-6.
Fractures involving splitting of the humeral head.
White TO, Robinson CM.
Publication Types:
    Comment
    Letter
PMID: 12358377 [PubMed - indexed for MEDLINE]
12: J Bone Joint Surg Br. 2001 Nov;83(8):1209-10. 
Comment on:
    J Bone Joint Surg Br. 2001 Apr;83(3):423-6.
Fractures involving splitting of the humeral head.
Ogawa K.
Publication Types:
    Comment
    Letter
PMID: 11764443 [PubMed - indexed for MEDLINE]
13: J Bone Joint Surg Br. 2001 Apr;83(3):423-6. 
Comment in:
    J Bone Joint Surg Br. 2001 Nov;83(8):1209-10.
    J Bone Joint Surg Br. 2002 Sep;84(7):1084; author reply 1084-5.
Fractures involving splitting of the humeral head.
Chesser TJ, Langdon IJ, Ogilvie C, Sarangi PP, Clarke AM.
Bristol Royal Infirmary, Southmead Hospital, UK.
Splitting fractures of the humeral head are rare; part of the humeral head
dislocates and the unfractured part remains attached to the shaft. We report
eight cases in young patients. In five the diagnosis was made at presentation:
three had minimal internal fixation using a superior subacromial approach, one
had a closed reduction and one a primary prosthetic replacement. All five
patients regained excellent function with no avascular necrosis at two years. In
three the injury was initially unrecognised; two developed a painless bony
ankylosis and one is awaiting hemiarthroplasty. It is important to obtain the
three trauma radiographic views to diagnose these unusual fractures reliably. CT
delineates the configuration of the fracture. In young patients open reduction
and internal fixation seems preferable to replacement of the humeral head, since
we have shown that the head is potentially viable.
PMID: 11341432 [PubMed - indexed for MEDLINE]
14: J South Orthop Assoc. 1995 Spring;4(1):3-8. 
Internal fixation of proximal humeral fractures.
Dahners LE.
Division of Orthopaedics, University of North Carolina, Chapel Hill 27599-7055,
USA.
Fractures of the proximal humerus are common, especially in elderly individuals,
and are usually classified according to Neer into fractures having one, two,
three, or four parts with or without an associated dislocation or an injury
splitting the humeral head. This article is intended to assist the surgeon in
selecting and using techniques for internal fixation of these fractures. The use
of open reduction and internal fixation using plates and screws has become less
popular because of the extensive dissection required and the tendency for the
plate to impinge. Use of multiple percutaneous pins to fix the humeral head to
the shaft (surgical neck) and heavy sutures or wires to reattach the
tuberosities is often preferable.
PMID: 7767676 [PubMed - indexed for MEDLINE]