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. 2023 Nov 15;244(3):448–457. doi: 10.1111/joa.13976

Axillary arch (of Langer): A large‐scale dissection and simulation study based on unembalmed cadavers of body donors

Jeremias T Weninger 1, Paata Pruidze 1,✉, Giorgi Didava 1, Tobias Rossmann 1,2, Stefan H Geyer 1, Stefan Meng 1, Wolfgang J Weninger 1
PMCID: PMC10862185  PMID: 37965841

Abstract

Connective or muscular tissue crossing the axilla is named axillary arch (of Langer). It is known to complicate axillary surgery and to compress nerves and vessels transiting from the axilla to the arm. Our study aims at systematically researching the frequency, insertions, tissue composition and dimension of axillary arches in a large cohort of individuals with regard to gender and bilaterality. In addition, it aims at evaluating the ability of axillary arches to cause compression of the axillary neurovascular bundle. Four hundred axillae from 200 unembalmed and previously unharmed cadavers were investigated by careful anatomical dissection. Identified axillary arches were examined for tissue composition and insertion. Length, width and thickness were measured. The relation of the axillary arch and the neurovascular axillary bundle was recorded after passive arm movements. Twenty‐seven axillae of 18 cadavers featured axillary arches. Macroscopically, 15 solely comprised muscular tissue, six connective tissue and six both. Their average length was 79.56 mm, width 7.44 mm and thickness 2.30 mm. One to three distinct insertions were observed. After passive abduction and external rotation of the arm, 17 arches (63%) touched the neurovascular axillary bundle. According to our results, 9% of the Central European population feature an axillary arch. Approximately 50% of it bilaterally. A total of 40.74% of the arches have a thickness of 3 mm or more and 63% bear the potential of touching or compressing the neuromuscular axillary bundle upon arm movement.

Keywords: axilla, axillopectoral muscle, chondroepitrochlearis muscle, thoracic outlet syndrome, variation

Nine percent of the Central European population has an axillary arch. Approximately half of these are bilateral. A total of 40.74% of the arches have a thickness of 3 mm or more, and 63% can touch or compress the neuromuscular axillary bundle during arm movements.

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1. INTRODUCTION

The axilla is a clinically important region of highly complex topology. It harbours lymph nodes and vessels, the stems of the large arteries and veins of the upper limb, the fascicles of the brachial plexus and the nerves formed by them. Anteriorly and posteriorly, it is bordered by the axillary folds, which are formed by the pectoralis major and latissimus dorsi muscle. The distal opening of the axilla is crossed by the main stems of the deep nerves, lymph and blood vessels, which supply, drain and innervate the tissues of the free upper limb.

A frequent variation in the axilla is the so‐called axillary arch. It is a strand of connective or muscular tissue, that splits from the latissimus dorsi muscle, crosses the axilla and joins the anterior part of the upper limb. The first detailed description of this variation was published in 1846 by Karl Langer Ritter von Edenberg (Langer, 1846). It quickly caused extensive anatomical interest and triggered extensive discussions about the evolutionary origin of this muscle (Birmingham, 1889; Frey, 1921; Gehry, 1903; Gruschka, 1911; Ruge, 1914; Sicher, 1911; Tobler, 1902).

But axillary arches are not only of interest for anatomists and evolutionary biologists, they are also of clinical relevance. In the last decades, it became more and more evident that they might cause symptoms of thoracic outlet syndrome (TOS) (Besana‐Ciani & Greenall, 2005; Clarys et al., 1996; Georgiev et al., 2007; Hafner et al., 2010; Magee et al., 2012). TOS is characterized by paraesthesia, compressional pain, muscle weakness, oedema and thrombosis in the distal upper limbs (DiLosa & Humphries, 2021; Illig et al., 2021; Seifert et al., 2017; Stewman et al., 2014), and might be caused by compression of nerves and blood and lymph vessels (Besana‐Ciani & Greenall, 2005; Boontje, 1979; Mérida‐Velasco et al., 2003; Sachatello, 1977; Telisky & Olinger, 2011). The highest compressional intensity of axillary arches is supposed to occur in abducted and externally rotated arms. Indeed, there are case reports on patients who suffer from TOS, feature an axillary arch and, by their profession (waitresses, swimmers) have to repetitively and extensively perform such movements (Hafner et al., 2010; Herbst & Miller, 2013).

Axillary anatomy in individuals featuring axillary arches differs from axillary anatomy described as norm situation. Although comprehensive traditional textbooks acknowledge this variation (Henle, 1871; Testut, 1884; Waldeyer, 2012), interventionalists and surgeons might become confused during clinical examination, harvesting of biopsies of axillary lymph nodes or trans‐axillary surgery (Endres, 1893; Hong et al., 2015; Markou et al., 2023; Scrimgeour et al., 2020). Thus, awareness of the possibility to meet axillary arches during interventions and profound knowledge of their connections, dimensions, appearance and tissue composition is critical for radiologists and surgeons.

Both, anatomical curiosity and the clinical impact of axillary arches triggered a number of studies, aiming for researching its nature and frequency (Ando et al., 2010; Cunningham, 1889; Douvetzemis et al., 2019; Georgiev et al., 2007; Guy et al., 2011; Kalaycioglu et al., 1998; Markou et al., 2023; Mérida‐Velasco et al., 2003; Natsis et al., 2010; Pai et al., 2006; Taterra et al., 2019). Interestingly, a recent meta‐analysis and reviews show that these studies provide highly different prevalences, ranging from 1.7% to 43.8% (Georgiev et al., 2007; Hirtler, 2014; Markou et al., 2023; Taterra et al., 2019). These discrepancies might partially reflect ethnicity and the methods used for detecting axillary arches. For example, studies relying on in vivo imaging often miss small axillary arches formed by connective tissue (Pruidze et al., 2023) and the frequency of axillary arches in Turkey seems to be significantly lower and in China significantly higher than in other nations (Kalaycioglu et al., 1998; Wagenseil, 1927).

Independent from ethnicity, the most realistic results are to be expected from studies relying on physical dissection of cadavers. However, access to precious cadaver material is often limited. Therefore, many anatomical studies were forced to either rely on relatively small numbers of specimens, use separated limbs or examine already prepared and embalmed material, collected after or while being dissected in dissection classes (Cunningham, 1889; Douvetzemis et al., 2019; Georgiev et al., 2007; Mérida‐Velasco et al., 2003; Pai et al., 2006). The latter also had to accept fixation artefacts, such as inhomogeneous shrinkages, unnatural tissue rigidity and others, that lower the accuracy of measurements.

We therefore decided to systematically examine the 400 axillae of 200 unembalmed cadavers, who had not been previously used for teaching or been included in other scientific projects. In this sample, we aimed to examine the frequency, gender distribution, uni‐ or bilaterality, macroscopic tissue composition and dimensions of axillary arches and to test whether they have the potential to touch or compress the neurovascular axillary bundle in abducted and externally rotated upper limbs.

2. MATERIALS AND METHODS

The study was performed in accordance with the local institutional review board (EK Nr: 1273/2020). All persons authorized donation of their bodies by signed informed consent before death.

Four hundred axillae from 200 (100 female, 100 male), unembalmed cadavers, aged between 50 and 101 years (mean 82.2) were investigated between August 2020 and May 2023. Only cadavers were used that arrived at our institute within 1–3 days post‐mortem, had not been previously used for research or teaching and, upon physical examination, lacked pathologies or scars at or near the armpits. Some results of 100 of those cadavers have also been included in a study examining the detectability of axillary arches in routine ultrasound examinations (Pruidze et al., 2023).

The bodies were anatomically dissected using traditional anatomical approaches and instruments. They were placed in supine position on a dissection table, arms abducted into 60 degrees. Using scalpel and forceps, the skin, covering axilla, axillary folds and parts of the lateral thorax and proximal brachium were removed (Figure 1a–d). Then, the anterior margin of the latissimus dorsi muscle was exposed near its origin and followed towards the axillary region. Connective tissue and muscle strands connected to it were carefully exposed until all their insertions were clearly visible. Finally, the borders of the axilla and the neurovascular bundle were fully exposed.

FIGURE 1.

FIGURE 1

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Frequent insertions (arrowheads) of axillary arches (asterisk). Double headed arrows indicate proximal (P) and distal (D). (a–d) Scheme demonstrating the area exposed by microdissection on the right (a, b) and left body side (c, d). (e–j) Cadaver specimens. Inlays show displayed specimens in lower magnification. The boxed area in the inlay is the field of view of the panel. (e, f) Single insertion of the axillary arch (asterisk) at deep aspect of the pectoralis major muscle tendon (PM). The muscle is cut from its origins and flipped anterolaterally. Note that in F also the axillary arch is cut and flipped medially to expose the neurovascular bundle (NB) transiting the axilla. (g) Insertion of axillary arch in the fascia covering the superficial aspect of the coracobrachialis muscle and the short head of the biceps brachii muscle (BCM). (h) Insertion of axillary arch in the deep fascia and tendon of the pectoralis major, the connective tissue sheath covering the deep surface of the pectoralis minor muscle, before reaching the coracoid process (PMI) and fascia covering the superficial aspect of the coracobrachialis muscle and the short head of the biceps brachii muscle. (i) Insertion at greater tubercle of the humerus, independently from the tendon of the pectoralis major muscle. (j) Insertion at coracoid process and fascia covering the superficial aspect of the coracobrachialis muscle and the short head of the biceps brachii muscle; UL, upper limb; TH, thorax; LD, latissimus dorsi muscle; TM, triceps brachii muscle. Scalebars 2 cm.

Origin, insertion, course and macroscopic tissue quality of identified axillary arches and their relationship to the neurovascular bundle were recorded and photo documented. Length, width and thickness of the axillary arches were measured using a ruler (AFS Medical GmbH, Interval 1 mm) and a calliper gauge (Herbert Müllner Werkzeuggrosshandel GmbH, Interval 0.05 mm).

In a final step, the arm was maximally abducted and externally rotated and the relationship between axillary arch and neurovascular bundle was documented.

SPSS Statistics 29.0 (IBM, New York, USA) was used for descriptive statistics, statistical tests and statistical visualization. GraphPad Prism 9 (GraphPad Software Inc.) and Photoshop Elements 2020 were used for the creation of figures.

Anatomical terms were used according to the official Terminologia Anatomica (TA) and publications by Kachlik et al. (FIPAT, 2019; Kachlik et al., 2017; Kachlík et al., 2020).

3. RESULTS

Twenty‐seven of the 400 examined axillae (6.75%, 15 female, 12 male) and 18 of the 200 cadavers (9%, nine female, nine male) had an axillary arch. In nine individuals (six female, three male), it existed bilaterally, and in another nine (three female, six male) unilaterally (Table 1).

TABLE 1.

Characteristics of identified axillary arches. Information on sex, age, side, type, thickness, width, touch of neurovascular bundle (nb) and insertion is provided.

Sex Age (years) Side Type Thickness (mm) Width (mm) Touching nb Insertion
Male 64 Right Muscular 3 11 Yes pm/gt
Left Muscular 4 14 Yes
Female 78 Right Muscular 5 5 Yes pm
Left Muscular 2 7 Yes bcm/cp
Female 80 Right Muscular 2 19 Yes bcm/cp
Left Muscular 1 8 No bcm/cp/pmi
Female 82 Right Muscular 3 9 Yes pm/me
Left Muscular 3 9 Yes pm/bcm/me
Female 81 Right Mixed 1 4 No pm/bcm
Left Muscular 2 6 Yes
Female 95 Right Muscular 1 8 Yes bcm
Left Mixed 2 5 Yes
Female 77 Right Mixed 1 5 No bcm/cp/pmi
Left Mixed 3 12 Yes pm/bcm/pmi
Male 82 Right Connective 3 1 No bcm
Left Connective 2 1 No bcm/cp
Male 83 Right Connective 1 7 No bcm/cp/pmi
Left Connective 1 4 No
Male 60 Left Muscular 4 10 Yes pm
Female 74 Left Muscular 3 3 No pm
Male 77 Left Muscular 3 12 Yes pm/bcm/cp
Male 81 Left Muscular 4 5 Yes pm/cp
Female 81 Left Muscular 3 11 Yes bcm/pm
Female 82 Left Mixed 1 3 No pm
Male 91 Left Mixed 2 5 Yes pm/bcm
Male 80 Left Connective 1 10 No pm/bcm/cp
Male 97 Right Connective 1 2 No bcm
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Note: Muscular, axillary arches macroscopically composed of muscular tissue; Connective, axillary arch macroscopically composed of connective tissue; Mixed, axillary arch macroscopically composed of both, muscular and connective tissue; pm, pectoralis major muscle; gt, greater tubercle of humerus; bcm, fascia covering the superficial aspect of the coracobrachialis muscle and the short head of the biceps brachii muscle; cp, coracoid process of scapula; me, medial epicondyle of the humerus; pmi, pectoralis minor muscle.

All arches originated from the latissimus dorsi muscle, but one arch had an additional origin from the axillary fascia. The insertion of the arches broadly varied. Sixteen arches (nine female, seven male) joined the deep fascia and then the deep side of the tendon of the pectoralis major muscle; two (two male) the greater tubercle of the humerus; 12 (four female eight male) the coracoid process of the scapula directly; 19 (11 female, eight male) the fascia covering the superficial aspect of the coracobrachialis muscle and the short head of the biceps brachii muscle, before reaching the coracoid process, five (three female, two male) the connective tissue sheath covering the superficial surface of the pectoralis minor muscle (clavipectoral fascia), before reaching the coracoid process (Figure 1e–k) and two (two female) the medial epicondyle of the humerus via the tendon of a chondroepitrochlearis muscle. (Figure 2). Eight arches inserted in only one of the described structures, while 11 simultaneously inserted at two and eight at three of the described structures (Figure 3a).

FIGURE 2.

FIGURE 2

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Unusual axillary arches (white asterisk) in an 82‐year‐old female cadaver. Note the insertion at the medial epicondyle of the humerus (ME) via a chondroepitrochlearis muscle tendon (yellow asterisk). Double headed arrow indicates proximal (P) and distal (D). (a) Dissected right upper arm. (b, c) Detail of insertion at the medial epicondyle of the humerus (b) and pectoralis major muscle (PM) (c). (d) Dissected left upper arm. (e, f) Details of insertion at the medial epicondyle of the humerus (e) and the fascia covering the superficial aspect of the coracobrachialis muscle and the short head of the biceps brachii muscle (BCM). LD, latissimus dorsi muscle; NB, neurovascular bundle; TM, triceps brachii muscle; DM, deltoid muscle; UN, ulnar nerve; MN, median nerve; GU, groove for ulnar nerve. Scalebars 2 cm.

FIGURE 3.

FIGURE 3

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Characterization of axillary arches. (a) Insertions of axillary arches (n = 27) according to the principally reached locations and in respect to combined insertions. (b) Tissue composition in relation to dimensions. (c) Dimensions and macroscopic tissue composition in relation to the ability to touch the axillary neurovascular bundle (nb) at maximal abduction and external rotation of the arm. Brown dots, axillary arches macroscopically solely composed of muscular tissue; blue dots, axillary arches macroscopically solely composed of connective tissue; green dots, axillary arches macroscopically composed of muscular and connective tissue. pm, pectoralis major muscle; bcm, fascia covering the superficial aspect of the coracobrachialis muscle and the short head of the biceps brachii muscle; cp, coracoid process; pmi, pectoralis minor muscle; gt, greater tubercle of the humerus; me, medial epicondyle of the humerus.

Macroscopically, 15 arches (10 female, five male) solely comprised muscular tissue, six (all male) solely connective tissue and six (five female one male) were composed of both, muscular and connective tissue (Figure 4).

FIGURE 4.

FIGURE 4

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Macroscopical tissue composition of axillary arches (asterisk). Inlay demonstrates laterality of specimen. Double headed arrow indicates proximal (P) and distal (D). (a) Axillary arch macroscopically solely composed of muscular tissue. (b) Axillary arch macroscopically composed of both, muscular and connective tissue. (c) Axillary arch macroscopically solely composed of fibrous tissue. PM, pectoralis major muscle; BCM, fascia covering the superficial aspect of the coracobrachialis muscle and the short head of the biceps brachii muscle; NB, neurovascular bundle; LD, latissimus dorsi muscle; PMI, pectoralis minor muscle. Scalebars 2 cm.

The mean length of the arches was 79.56 mm, the mean width was 7.44 mm and the mean thickness was 2.30 mm. The thickest arches were macroscopically solely comprised of muscular tissue, the thinnest arches predominantly of connective tissue (Figure 3).

In 17 of 27 cases (four bilateral), the neurovascular bundle passing beneath an axillary arch was at least touched after abduction and external rotation of the arm. The arches touching the neurovascular bundle were by far thicker and broader than the arches that did not touch. Except for two, all arches that touched the bundle were macroscopically solely composed of muscular tissue. On the contrast, all arches solely composed of connective tissue did not touch it (Figure 3).

Fourteen (eight female, six male) axillary arches ran in a curve with the apogee directed caudally. Their course was fixed by the axillary fascia. Six were macroscopically solely composed of connective tissue, three of connective and muscular tissue and five of muscular tissue only. Curved axillary arches were present bilaterally in three cadavers, unilaterally in five. Three cadavers with bilateral axillary arches showed this course on only one side. Upon abduction and external arm rotation, only three of those curved arches touched the axillary neurovascular bundle.

4. DISCUSSION

The axillary arch is a well‐documented anatomical variant, which is linked to pathologies, such as thoracic outlet syndrome. Therefore, a rather large number of studies were already published, which researched the frequency and composition of axillary arches in probands, patients and cadavers (Ando et al., 2010; Guy et al., 2011; Markou et al., 2023; Taterra et al., 2019). The results are already included in anatomical textbooks (Henle, 1871; Testut, 1884; Waldeyer, 2012). A recent meta‐analysis and a detailed review comprehensively discuss and provide tables comparing the results (Markou et al., 2023; Taterra et al., 2019).

Yet, axillary arches are sometimes relatively small, hindering their detection with in vivo radiological imaging techniques (Ando et al., 2010; Guy et al., 2011; Pruidze et al., 2023). Therefore, the majority of studies examining axillary arches made use of traditional anatomical dissection (Cunningham, 1889; Douvetzemis et al., 2019; Georgiev et al., 2007; Kalaycioglu et al., 1998; Mérida‐Velasco et al., 2003; Natsis et al., 2010; Pai et al., 2006). Since the availability of cadaver material is limited, most of these dissection studies examined relatively small numbers of specimens or used embalmed material, which sometimes had even been already pre‐dissected in student dissection classes (Cunningham, 1889; Douvetzemis et al., 2019; Georgiev et al., 2007; Mérida‐Velasco et al., 2003). Others had to rely on examining severed arms instead of the corresponding left and right arms of the same individuals (Guy et al., 2011; Karanlik et al., 2013). Our study systematically examines both sides of 200 cadavers, who arrived at our institute 1–3 days after the death of the body donors. None of them had been included in teaching or research prior to dissection for this study. The large number of 400 examined axillae, the possibility to compare sides and the fact that we only used previously undissected, unembalmed cadavers without visible diseases in or near the axillae make our data a highly accurate and valuable resource for anatomists and clinicians.

According to existing studies, axillary arches occur in 1.7%–43.8% of the population (Georgiev et al., 2007; Hirtler, 2014). The enormous differences in identification may result from relatively small numbers of specimens examined, from the use of severed arms instead of both sides of the same individual, and from examining different ethnic groups (Karanlik et al., 2013). Our findings are based on bilateral examination of 200 cadavers recruited from a Central European society. Hence, according to our findings, an axillary arch can be expected in Caucasians in 9% of the individuals and in 6.75% of their axillae. The obvious discrepancy in numbers reflects that 50% of the axillary arches occur unilaterally and 50% bilaterally. It is therefore highly relevant to consider whether frequency refers to the presence of axillary arches in axillae of single arms or to its presence in individuals.

Our data suggest that axillary arches occur as frequently in men as in women; however, it opens the hypothesis that axillary arches occur more often bilaterally in women (six individuals) than in men (three individuals). Nevertheless, these findings must be set in context of the number of examined specimens. Despite examining 400 axillae of 200 individuals, the basis for the female/male ratio are 27 axillae and 18 individuals respectively.

In addition to providing information on frequency, we also provide information on the insertions, dimensions and composition of the axillary arches. For assessing the tissue composition, we solely relied on the macroscopic aspect. We did not conduct systematic histological examinations of the axillary arches. Therefore, we cannot provide information on the types of collagens comprising axillary arches formed by connective tissue. Also, we cannot exclude that solitary muscle fibres were merged between connective tissue fibres in axillary arches classified as axillary arches consisting of connective tissue or provide data on the precise relationship of tissues in different portions of the axillary arches. However, the rough macroscopic classification system we used provide comprehensive macro‐anatomical information and should be sufficient for clinical needs. According to this system, the majority (55.56%) of the 27 detected axillary arches were macroscopically composed of muscular tissue and were rather broad and thick. On the contrary, arches macroscopically consisting of connective tissue were, as expected, rather thin. The clinical impact of this is that the thick, predominantly muscular axillary arches, which might cause symptoms of TOS are quite easily detectable in ultrasound examinations (Pruidze et al., 2023).

All axillary arches connected anteriorly to the anterior rim of the latissimus dorsi muscle and only one had additional fibres originating in the axillary fascia. In contrast, the arches inserted at a rather broad spectrum of anatomical structures ranging from the medial epicondyle of the humerus to the coracoid process. However, the vast majority at least with one insertion ultimately reached the coracoid process—either directly, or via the fasciae and tendons of the muscles connecting to it. Except for the chondroepitrochlearis muscle tendon, all insertion positions we detected were also noticed more than 100 years ago by Ruge (Ruge, 1905, 1910, 1914). Furthermore, Ruge mentions that pectoralis minor muscle insertions are at highest 2.5 cm away from its insertion at the coracoid process (Ruge, 1914). This statement is verified by our results.

In general, we identified axillary arches, that left the latissimus dorsi muscle to take a straight cranial course and others, that passed the axilla in a curve with the apogee directed caudally. The latter were firmly fixed in the axillary fascia, which secured the peculiar course. Only a small number of curved axillary arches (three out of 14) touched the neurovascular bundle upon abduction and external arm rotation. This was expected, since the curved course provides sufficient length reserves during arm movements.

An 82‐year‐old female cadaver bilaterally showed axillary arches and chondroepitrochlearis muscles. The chondroepitrochlearis muscle is a very rare variant. Its belly splits from the abdominal part of the pectoralis major muscle, forms a very long tendon and inserts at the medial epicondyle of the humerus (Spinner et al., 1991; Voto & Weiner, 1987). Quite often its presence is associated with the occurrence of an axillary arch (Chiba et al., 1983; Nakajima et al., 1999). Although bilateral occurrence of a chondroepitrochlearis muscle was recently reported (Flaherty et al., 1999; Palagama et al., 2016), bilateral occurrence of chondroepitrochlearis muscles, associated with the bilateral presence of axillary arches was not yet described. Interestingly, the arches of both sides touched the neurovascular axillary bundle in abduction and external arm rotation.

The presence of an axillary arch is blamed as a potential cause of TOS (Besana‐Ciani & Greenall, 2005; Clarys et al., 1996; Georgiev et al., 2007; Hafner et al., 2010). We examined the axillae of unharmed and fresh (unembalmed) cadavers. Therefore, the tissues were not altered and shrunken by fixation. Morphometric parameters could be precisely measured and the specimens could be even used for accurately examining positional shifts of axillary structures when performing passive arm movements. Hence, we decided to evaluate whether arm abduction and external rotation have the potential to cause compression of the neurovascular bundle transiting from the axilla into the medial bicipital sulcus. Our simulations revealed that in maximal arm abduction and external rotation, 63% of the axillary arches are in tight contact with the neuromuscular bundle. We consider this as a sign that these arches have the potential to cause symptoms usually associated with thoracic outlet syndrome and paraesthesia.

Importantly, all axillary arches that touched the neuromuscular axillary bundle upon arm abduction and external rotation are thick and broad and are macroscopically formed by muscular tissue or at least contain it. The large dimensions and compositions of these arches offer the possibility to detect potentially symptomatic axillary arches with high‐resolution ultrasound. First results of testing this hypothesis are encouraging (Pruidze et al., 2023). They pave the way to clinical evaluation and application of the diagnosis of potentially symptomatic axillary arches by using ultrasound in patients suffering from symptoms of TOS.

AUTHOR CONTRIBUTION

Jeremias T. Weninger: Study design, dissection, original draft and figures. Paata Pruidze: Study design, logistics, critical revision and supervision of dissection. Giorgi Didava: Dissection. Tobias Rossman: Data evaluation, data management and statistics. Stefan Geyer: Table, descriptive statistics and critical revision. Stefan Meng: Study design, cadaver logistics and dissection. Wolfgang J. Weninger: Study design, critical revision and supervision of dissection.

FUNDING INFORMATION

This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.

ETHICS STATEMENT

This cross‐sectional cadaver study has been performed in accordance with the local institutional review board of Medical University of Vienna (EK Nr: 1273/2020).

ACKNOWLEDGEMENTS

The authors sincerely thank those who donated their bodies to science so that anatomical research could be performed. Results from such research can potentially improve patient care and increase mankind's overall knowledge. Therefore, these donors and their families deserve our highest gratitude. We acknowledge the contribution of Atieh Seyedian Moghaddam for her assistance during documentation.

Weninger, J.T. , Pruidze, P. , Didava, G. , Rossmann, T. , Geyer, S.H. , Meng, S. et al. (2024) Axillary arch (of Langer): A large‐scale dissection and simulation study based on unembalmed cadavers of body donors. Journal of Anatomy, 244, 448–457. Available from: 10.1111/joa.13976

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available upon reasonable request.

REFERENCES

  1. Ando, J. , Kitamura, T. , Kuroki, Y. & Igarashi, S. (2010) Preoperative diagnosis of the axillary arch with multidetector row computed tomography and the axillary arch in association with anatomical problems of sentinel lymph node biopsy. Breast Cancer, 17, 3–8. [DOI] [PubMed] [Google Scholar]
  2. Besana‐Ciani, I. & Greenall, M.J. (2005) Langer's axillary arch: anatomy, embryological features and surgical implications. The Surgeon, 3, 325–327. [DOI] [PubMed] [Google Scholar]
  3. Birmingham, A. (1889) Homology and innervation of the achselbogen and pectoralis quartus, and the nature of the lateral cutaneous nerve of the thorax. Journal of Anatomy and Physiology, 23, 206–223. [PMC free article] [PubMed] [Google Scholar]
  4. Boontje, A.H. (1979) Axillary vein entrapment. British Journal of Surgery, 66, 331–332. [DOI] [PubMed] [Google Scholar]
  5. Chiba, S. , Suzuki, T. & Kasai, T. (1983) A rare anomaly of the pectoralis major? The chondroepitrochlearis. Okajimas Folia Anatomica Japonica, 60, 175–185. [DOI] [PubMed] [Google Scholar]
  6. Clarys, J.P. , Barbaix, E. , Van Rompaey, H. , Caboor, D. & Van Roy, P. (1996) The muscular arch of the axilla revisited: its possible role in the thoracic outlet and shoulder instability syndromes. Manual Therapy, 1, 133–139. [DOI] [PubMed] [Google Scholar]
  7. Cunningham, D. (1889) Report of the Committee of Investigation in the Anatomical Department of Trinity College. Session 1888–1889. Transactions of the Royal Academy of Medicine in Ireland, 7, 378–387. [Google Scholar]
  8. DiLosa, K.L. & Humphries, M.D. (2021) Epidemiology of thoracic outlet syndrome. Seminars in Vascular Surgery, 34, 65–70. [DOI] [PubMed] [Google Scholar]
  9. Douvetzemis, S. , Natsis, K. , Piagkou, M. , Kostares, M. , Demesticha, T. & Troupis, T. (2019) Accessory muscles of the anterior thoracic wall and axilla. Cadaveric, surgical and radiological incidence and clinical significance during breast and axillary surgery. Folia Morphologica, 78, 606–616. [DOI] [PubMed] [Google Scholar]
  10. Endres, H.E. (1893) Ueber ein Zwischenmuskelbündel im Gebiete des M. pectoralis maior und latissimus dorsi. Anatomischer Anzeiger, 8, 387–397. [Google Scholar]
  11. FIPAT . (2019) FIPAT.library.dal.ca
  12. Flaherty, G. , O'Neill, M.N. & Folan‐Curran, J. (1999) Case report: bilateral occurrence of a chondroepitrochlearis muscle. The Journal of Anatomy, 194(Pt 2), 313–315. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Frey, H. (1921) Über einen Fall von zusammengesetztem Achselbogen beim Menschen. Gegenbaurs Morphologisches Jahrbuch, 51, 259–277. [Google Scholar]
  14. Gehry, K. (1903) Neue Beiträge zur Geschichte des Achselbogens des Menschen, eines Rudimentes des Panniculus carnosus der Mammalier. Gegenbaurs Morphologisches Jahrbuch, 31, 446–452. [Google Scholar]
  15. Georgiev, G.P. , Jelev, L. & Surchev, L. (2007) Axillary arch in Bulgarian population: clinical significance of the arches. Clinical Anatomy, 20, 286–291. [DOI] [PubMed] [Google Scholar]
  16. Gruschka, T. (1911) Über einen Fall von zusammengesetztem Achselbogen beim Menschen. Gegenbaurs Morphologisches Jahrbuch, 43, 359–368. [Google Scholar]
  17. Guy, M.S. , Sandhu, S.K. , Gowdy, J.M. , Cartier, C.C. & Adams, J.H. (2011) MRI of the axillary arch muscle: prevalence, anatomic relations, and potential consequences. American Journal of Roentgenology, 196, W52–W57. [DOI] [PubMed] [Google Scholar]
  18. Hafner, F. , Seinost, G. , Gary, T. , Tomka, M. , Szolar, D. & Brodmann, M. (2010) Axillary vein compression by Langer's axillary arch, an aberrant muscle bundle of the latissimus dorsi. Cardiovascular Pathology, 19, e89–e90. [DOI] [PubMed] [Google Scholar]
  19. Henle, J. (1871) Handbuch der systematischen Anatomie des Menschen: Bd. 1. Abt. Muskellehre. 3. Aufl. 2. Braunschweig: Friedrich Vieweg und Sohn. [Google Scholar]
  20. Herbst, K.A. & Miller, L.S. (2013) Symptomatic axillopectoral muscle in a swimmer: a case report. The American Journal of Sports Medicine, 41, 1400–1403. [DOI] [PubMed] [Google Scholar]
  21. Hirtler, L. (2014) Langer's axillary arch‐case presentation and literature overview. Austin Journal of Anatomy, 1, 1020–1025. [Google Scholar]
  22. Hong, H.J. , Choi, N.J. , Han, D.H. & Ahn, M.I. (2015) Axillary arch: detailed ultrasonographic images with multiplanar CT correlation. Journal of Medical Ultrasonics, 42, 121–125. [DOI] [PubMed] [Google Scholar]
  23. Illig, K.A. , Rodriguez‐Zoppi, E. , Bland, T. , Muftah, M. & Jospitre, E. (2021) The incidence of thoracic outlet syndrome. Annals of Vascular Surgery, 70, 263–272. [DOI] [PubMed] [Google Scholar]
  24. Kachlik, D. , Musil, V. & Baca, V. (2017) Contribution to the anatomical nomenclature concerning upper limb anatomy. Surgical and Radiologic Anatomy, 39, 405–417. [DOI] [PubMed] [Google Scholar]
  25. Kachlík, D. , Varga, I. , Báča, V. & Musil, V. (2020) Variant anatomy and its terminology. Medicina (Kaunas, Lithuania), 56, 713. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Kalaycioglu, A. , Gümüsalan, Y. & Ozan, H. (1998) Anomalous insertional slip of latissimus dorsi muscle: arcus axillaris. Surgical and Radiologic Anatomy, 20, 73–75. [DOI] [PubMed] [Google Scholar]
  27. Karanlik, H. , Fathalizadeh, A. , Ilhan, B. , Serin, K. & Kurul, S. (2013) Axillary arch may affect axillary lymphadenectomy. Breast Care, 8, 424–427. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Langer, C. (1846) Zur Anatomie des Musculus latissimus dorsi. Oesterreichische medicinische Wochenschrift, 15, 454–458. [Google Scholar]
  29. Magee, C. , Jones, C. , McIntosh, S. & Harkin, D.W. (2012) Upper limb deep vein thrombosis due to Langer's axillary arch. Journal of Vascular Surgery, 55, 234–236. [DOI] [PubMed] [Google Scholar]
  30. Markou, M.A. , Kakagia, D.D. , Effraimidou, E.I. & Fiska, A.T. (2023) Anatomical variations of the axillary arch and implications in breast surgery. Journal of Surgical Research, 281, 176–184. [DOI] [PubMed] [Google Scholar]
  31. Mérida‐Velasco, J.R. , Rodríguez Vázquez, J.F. , Mérida Velasco, J.A. , Sobrado Pérez, J. & Jiménez Collado, J. (2003) Axillary arch: potential cause of neurovascular compression syndrome. Clinical Anatomy, 16, 514–519. [DOI] [PubMed] [Google Scholar]
  32. Nakajima, K. , Chiba, S. , Kobayashi, K. , Wakatuki, E. , Kumaki, K. & Hoshino, T. (1999) A rare muscular anomaly in the upper arm–the chondroepitrochlearis muscle with an aberrant type of the muscular arch of axilla. Kaibogaku Zasshi, 74, 209–213. [PubMed] [Google Scholar]
  33. Natsis, K. , Vlasis, K. , Totlis, T. , Paraskevas, G. , Noussios, G. , Skandalakis, P. et al. (2010) Abnormal muscles that may affect axillary lymphadenectomy: surgical anatomy. Breast Cancer Research and Treatment, 120, 77–82. [DOI] [PubMed] [Google Scholar]
  34. Pai, M.M. , Rajanigandha, P.L. , Shetty, P. & Narayana, K. (2006) Axillary arch (of Langer): incidence, innervation, importance. Online Journal of Health and Allied Sciences, 1, 5. [Google Scholar]
  35. Palagama, S.P. , Tedman, R.A. , Barton, M.J. & Forwood, M.R. (2016) Bilateral chondroepitrochlearis muscle: case report, phylogenetic analysis, and clinical significance. Anatomy Research International, 2016, 5402081. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Pruidze, P. , Rossmann, T. , Weninger, J.T. , Didava, G. , Seyedian Moghaddam, A. , Weninger, W.J. et al. (2023) Ultrasound detection of the axillary arch as a cause of thoracic outlet syndrome: a prospective dissection‐controlled cadaver study. Ultrasound in Medicine & Biology, 49, 946–950. [DOI] [PubMed] [Google Scholar]
  37. Ruge, G. (1905) Zusammenhang des M. sternalis mit der Pars abdominalis des M. pectoralis major und mittels dieser mit dem Achselbogen. Gegenbaurs Morphologisches Jahrbuch, 33, 348–373. [Google Scholar]
  38. Ruge, G. (1910) Ein Rest des Haut‐Rumpf‐Muskels in der Achselgegend des Menschen. Gegenbaurs Morphologisches Jahrbuch, 41, 519–538. [Google Scholar]
  39. Ruge, G. (1914) Der Hautrumpfmuskel des Menschen. Gegenbaurs Morphologisches Jahrbuch, 48, 1–75. [Google Scholar]
  40. Sachatello, C.R. (1977) The axillopectoral muscle (Langer's axillary arch): a cause of axillary vein obstruction. Surgery, 81, 610–612. [PubMed] [Google Scholar]
  41. Scrimgeour, G.E. , St John, E.R. & Leff, D.R. (2020) Langer's arch: a rare but important consideration for axillary surgery with implications for training. The Breast Journal, 26, 2226–2228. [DOI] [PubMed] [Google Scholar]
  42. Seifert, S. , Sebesta, P. , Klenske, M. & Esche, M. (2017) Thoracic‐Outlet‐Syndrom. Zentralblatt für Chirurgie‐Zeitschrift für Allgemeine, Viszeral‐, Thorax‐und Gefäßchirurgie, 142, 104–112. [DOI] [PubMed] [Google Scholar]
  43. Sicher, H. (1911) Zur Morphologie des Achselbogens beim Menschen. Gegenbaurs Morphologisches Jahrbuch, 43, 339–344. [Google Scholar]
  44. Spinner, R.J. , Carmichael, S.W. & Spinner, M. (1991) Infraclavicular ulnar nerve entrapment due to a chondroepitrochlearis muscle. The Journal of Hand Surgery, 16, 315–317. [DOI] [PubMed] [Google Scholar]
  45. Stewman, C. , Vitanzo, P.C., Jr. & Harwood, M.I. (2014) Neurologic thoracic outlet syndrome: summarizing a complex history and evolution. Current Sports Medicine Reports, 13, 100–106. [DOI] [PubMed] [Google Scholar]
  46. Taterra, D. , Henry, B.M. , Zarzecki, M.P. , Sanna, B. , Pękala, P.A. , Cirocchi, R. et al. (2019) Prevalence and anatomy of the axillary arch and its implications in surgical practice: a meta‐analysis. The Surgeon, 17, 43–51. [DOI] [PubMed] [Google Scholar]
  47. Telisky, A. & Olinger, A. (2011) Unique variation of the axillary arch muscle discovered during dissection could explain neurologic symptoms in the living patient. Clinical Anatomy, 24, 961–963. [DOI] [PubMed] [Google Scholar]
  48. Testut, L. (1884) Les anomalies musculaires chez l'homme: expliquées par l'anatomie comparée leur importance en anthropologie. Paris, France: Libraire de l'Academie de Medecine. [Google Scholar]
  49. Tobler, L. (1902) Der Achselbogen des Menschen, ein Rudiment des Panniculus carnosus der Mammalier. Gegenbaurs Morphologisches Jahrbuch, 30, 453–507. [Google Scholar]
  50. Voto, S.J. & Weiner, D.S. (1987) The chondroepitrochlearis muscle. Journal of Pediatric Orthopedics, 7, 213–214. [DOI] [PubMed] [Google Scholar]
  51. Wagenseil, F. (1927) Muskelbefunde bei Chinesen. Anthropologischer Anzeiger, Verhandlungen der Gesellschaft für Physikalische Anthropologie, 2, 42–51. [Google Scholar]
  52. Waldeyer, A.J. (2012) Waldeyer – Anatomie des Menschen. Berlin, Germany: Walter de Gruyter. [Google Scholar]

Associated Data

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Data Availability Statement

The data that support the findings of this study are available upon reasonable request.

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