The Frequency of Mediastinal Injury in Acute Posterior Sternoclavicular Dislocations: A Multicenter Study.

BACKGROUND: Acute posterior sternoclavicular dislocations (APSCD) are rare injuries that historically have prompted concern for injury to the great vessels and other mediastinal structures from initial trauma or subsequent treatment, resulting in the recommendation that a thoracic or vascular surgeon be present or available during operative treatment. The objectives of the study were to characterize the demographic, clinical, and radiographic characteristics of a large series of APSCDs in skeletally immature patients and to describe the rate and nature of any vascular or mediastinal complications that occurred during treatment. METHODS: Following Institutional Review Board approval, records of consecutive patients under 25 years of age treated for APSCD were collected from each of 6 participating centers. Only acute injuries (sustained fewer than 10 days before presentation) were included. Patient demographics, injury mechanism, associated mediastinal injuries, and need for thoracic/vascular surgery were recorded. Mediastinal structures injured or compressed by mass effect were specifically characterized by review of preoperative computed tomography imaging. RESULTS: Review identified 125 patients with a mean age of 14.7 years; 88% were male. APSCD most commonly resulted from a sporting injury (74%) followed by falls from standing height (10%) and high-energy motor vehicle trauma (10%). The most common finding on cross-sectional imaging was compression without laceration of the ipsilateral brachiocephalic vein (50%). Eleven patients had successful closed reduction, and 114 (90%) had open reduction and internal fixation, with 25 failed or unstable closed reductions preceding open treatment. There were no vascular or mediastinal injuries during reduction or fixation that required intervention. CONCLUSIONS: In this multicenter series of 125 APSCDs no injuries to the great vessels/mediastinal structures requiring intervention were identified. Although more than half of patients had evidence of extrinsic vascular compression at the time of injury, careful open reduction of acute injuries can be safely performed. Although vascular injuries following APSCD seem to be quite rare, vascular complications can be catastrophic. Treating providers should consider these data and their own institutional resources to maximize patient safety during the treatment of APSCD. LEVEL OF EVIDENCE: Level III-therapeutic case control study.

Comparative mapping reveals autosomal origin of sex chromosome in octoploid Fragaria virginiana.

Recent evolution of separate sexes in flowering plants provides unparalleled opportunities for understanding the early stages of sex chromosome evolution, including their origin from autosomes. Moreover, the transition from combined to separate sexes can be associated with speciation via polyploidization in angiosperms, suggesting that genome doubling/merger may facilitate sterility mutations required for sex chromosome formation. To gain insight into the origin of sex chromosomes in a polyploid plant, we doubled the simple sequence repeat (SSR) density and increased genome coverage in a genetic map of octoploid Fragaria virginiana, a species purported to have a "proto-sex" chromosome, where limited recombination occurs between 2 linked "loci" carrying the male- and female-sterility mutations. Incorporation of almost 3 times the number of SSR markers into the current map facilitated complete characterization of the F. virginiana proto-sex chromosome, revealing its largely autosomal nature and the location of the sex-determining region toward the distal end. Furthermore, extensive synteny between our genetic map and a map involving diploid hermaphroditic congeners allowed assignment of linkage groups to homeologous groups, identification of the proto-sex chromosome's autosomal homoeolog, and detection of a putative rearrangement near the sex-determining region. Fine mapping and additional comparative work will shed light on the intriguing possibility that rearrangements during polyploidization were involved in the evolution of sex chromosomes in Fragaria.