LANGER’S AXILLARY ARCH AND ITS CLINICAL IMPLICATIONS

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Int J Anat Res 2014, 2(3):481-84. ISSN 2321-4287 481

Case Report

LANGER’S AXILLARY ARCH AND ITS CLINICAL IM PLICATIONS

Jyothi K C *

1

_{, Anupama K}

2

_{, Shailaja Shetty}

3

_{, Radhika P M}

4

_.

ABSTRACT

Address for Correspondence: Dr Jyot hi K C, Assist ant Professor, Depart m ent of Anat omy, M . S. Ramaiah M edical College, M SRIT Post , Bangalore. 560054, India. M obile: +919731346464. E-M ail: jyot himohankc@gmail.com

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* 1,2,4_{Assistant Professor,}3_{Professor & Head.}

Depart ment of anat omy, M S Ramaiah M edical College, Bangalore, India.

Introduction: The axillary arch m uscle of Langer is t he m ost com m on anat om ical variant of axillary m usculat ure w hich is of clinical and surgical im portance. It m ay lead t o neurovascular com pression syndrom e in t he cervico-axi llary region and can be m isint erpret ed w hile exam ining cervico-axilla and also im pairs m ovem ent s of shoulder joint .

Observation: During rout ine dissect ion of axilla for undergraduat e t eaching, an unusual m uscular slip in t he lef t axilla w as observed .The m uscular slip w as ext ending f rom latt isim us dorsi m uscle t o undersur face of pect oralis m ajor m uscle, arching over axillary vessels and cords of brachial plexus.

Conclusion:The axillary arch m ay cause obst ruct ion t o axillary vessels and nerves and m ay be involved in t horacic out let syndrom e and shoulder instabilit y. The know ledge of t his m uscular variant could help t o m inim ize int raoperat ive com plicat ions relat ed t o surger ies in or near by axilla such as m ast ect omy, breast reconst ruct ion and axillary lym phadenect om y or lym ph node biopsy.

KEYW ORDS:Axi llary arch, Langer ’s m uscle, Axilla, Anom alous m uscle.

INTRODUCTION

Int ernat ional Journal of Anatomy and Research, Int J Anat Res 2014, Vol 2(3):481-84. ISSN 2321- 4287

Received: 27 June 2014

Peer Review : 27 June 2014 Published (O):31 July 2014 Accepted: 14 July 2014 Published (P):30 Sep 2014 Internat ional Journal of Anat omy and Research

ISSN 2321-4287 w w w.ijmhr.org/ ijar.ht m

Human beings are individualist ic creat ure and t his is reflected in t he human anat omy w hich is subject ed t o a large num ber of anat om ical variations. The axilla is a pyramidal area betw een t he upper t horacic wall and t he arm. It contains axillary vessels, cords and branches of brachial plexus, lymph nodes, and loose areolar t issue w it h fat and axi llary t ai l of breast in m any instances[1].

A number of accessory muscle slips may arise from Pect oralis m uscle or m ay be present in axi llar y region have been descr i bed under different names. These abnorm al m uscle slip may arise from lateral border of pect oralis major muscles, from ribs and costal cart ilages or from lat issimus dorsi muscle, midway in t he posterior

axillary fold crossing over t he axillary vessels and nerves and have variable insert ions [1.2].

The various terminologies used t o describe t his variant st ruct ure are, axillary arch, axillopect oral m uscle, Achselbogen, Langers axillar y arch, muscular axillary arch, arcus axillaris, pect oral dorsalis muscle [3].

It is stated t hat axillary arch muscles w ere first discovered by Ramsay in 1795 and Langer in 1846 was credited for t he first descript ion of t his clinically t roublesome variat ion [4].

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Int J Anat Res 2014, 2(3):481-84. ISSN 2321-4287 482 During rout ine dissect ion t eaching of axillary

region for undergraduate st udent s in Anat omy Depar t m ent , M S Ram aiah M edical College, Bangalore, w e found an anomalous muscle slip in t he left axilla.

Jyot hi K C, Anupama K, Shailaja Shet t y, Radhika P M . LANGER’S AXILLARY ARCH AND ITS CLINICAL IM PLICATIONS.

It is more commonly seen among Chinese t han in Caucasian populat ion. It is more common in females t han in males and is seen as bilateral variat ion t han unilateral [6].

Test ut referred t o it as the axillary arch of Langer in 1884 and classified t hese anomalous bands in to complete and incomplete types. The complete t yp e st rech es f rom t he axi l lar y por t ion of lat issim us dorsi t o t he post erior layer of t he pect oralis major tendon at it s insert ion on t he hum erus. The incom plete t ype extends from lat issi m us do rsi and does not in ser t in t o pect oralis m ajor t endon, but on t he axillary fascia, biceps brachii muscle, corachobrachialis muscle or t o t he coracoids process [7].

The nerve supply of t he axillary arch has been reported different in various literat ures. It has been reported t hat it receives nerve supply from t horacodorsal nerve, m edial pect oral nerve, intercost obrachial nerve [7,8,9].

It is w idely accepted t hat axillary arch muscle is a remnant of t he panniculus carnosus, and is an example of t he atavist ic t ype of muscle. M any o f t h ese are w el l dev elo p ed an d b et t er represented in apes t han in humans [2, 10].

The present paper report s a case of complete t ype of axillary arch and it s clinical implicat ions.

CASE REPORT

The muscle w as fleshy t hroughout it s lengt h, ext endin g f ro m lat t isim us do rsi m uscle t o undersurface of pect oralis major muscle. It mea-sured a lengt h of 8.5 cm, maximum w idt h of 3.8 cm at Pect oral end and 1.5 cm at lat iissim us dorsi. It was passing superficial t o t hird part of axillary vessels and cords and branches of bra-chial plexus. It was receiving nerve supply from a branch arising from posterior cord near the ori-gin of t horacodorsal nerve. (Fig. 1)

Fig. 1: Lef t Axi lla show ing Axillar y cont ent s and presence of Langer ’s Axillary Arch.

DISCUSSION

Smit h AR reported a case of bilateral incomplete t ype of anomalous musculotendinous bands in consistent w it h axillary arch of Langer in an 81 year old male cadaver dissected to teach physical t herapy st udent s. This band was said t o tauten and com press t he underlying neurovascular struct ures during passive abduct ion and external rotat ion of shoulder [11].

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In first t w o cadavers t here was possibilit y of com pression of t he neurovascular st ruct ures passing deep t o t he muscle band and can also cont ribute t o hyperabduct ion syndrome [7].

The clinicians should examine for t he presence of an axillary arch in pat ient s w it h signs and sy m pt o m s o f cer vico-axi llar y com pr essi on causing t horacic out let and hyper-abduct ion syndromes [7,12].

Langer ’s arch can be occasionally palpable as an axillary mass during clinical examination and can be confused w it h enlarged lymph nodes or soft t issue t umours [12].

In anot her st udy by Bertone VH et al, t hey found 9 axillary arches in 78 dissected axillae and stated t hat t he know ledge of such a muscle variat ion and t he possibilit y of finding it during surgical procedures is essent ial for lymph node staging and lymphadenect omy and also is important in different ially diagnosing t he com pression of axillary vessels and brachial plexus [9].

Hafner et al and Sachatello presented a similar case in 17 years old and 15 years old female p at i en t s r esp ect i vel y w ho cam e w i t h t h e complaint s of int erm itt ent sw elling, pain and bluish discolorat ion of arm w it h fullness of t he affect ed axilla and loss of norm al concavit y. Surgical explorat ion in bot h t he cases revealed t he presence of an aberrant muscle bundle. The sym pt om s resolved com plet ely after surgical resect ion of t he m uscle. Hence any pat ient s coming w it h t he above signs and sym pt om s should be examined for t he presence of axillary arch as excision of it is curat ive [13, 14].

The first extensive review of shoulder M RI data t o analyze t he axi llar y arch m uscle and it s anat om ic relat ions t o lym ph nodes and t he brachial plexus was carried out and concluded t hat M RI as t he m ost su i t ab l e m o d e o f ident ifying arch muscle in pat ient w it h upper limb pain and numbness [15].

Nat sis et al reported t he presence of t he t hree com m only encount ered anom alous m uscle bands during axillary lymphadenect omy t hrough ext ensive surgical and anat om ical lit erat ure r ev i ew as t h e Lan ger ’s axi l l ar y arch , t h e pect oralis quart us and t he chondroepit rochlearis muscles and stated t hat t he axillary arch may interfere in t he approach of t he axilla and cover

t he lateral group of level I lymph nodes, so t hat t hey m ay not be com plet ely cleared. Hence surgeons must be aware of the presence of these m uscles w it hin t he surgical field of axi llar y lymphdenect omy [16].

CONCLUSION

Unilateral complete t ype of axillary arch was found in 60 year old female cadaver. Anat omical variat ions of axilla are of great relevance due increasing surgical procedures done in t his region for for breast cancer, reconst ruct ive pro-cedures and axillary bypass operat ions. Fullness of axi lla w it h loss of nor m al concavit y and visible or palpable axillary mass may indicate t he presence of axi llar y arch. It should be considered in pat ient s w it h signs and symptoms of u pp er l im p neur ovascul ar com pr essi on similar t o t horacic out let syndrome and simple excision of t he m uscle is curat ive. Necessary preoperat ive know ledge for recognizing t hese muscles w ill avoid operat ive complicat ions t hat may arise from t hem.

AKNOW ELDGEM ENT

I t hank all t he aut hors w hose references have been quoted in t his paper and my colleagues for t heir support and encouragement .

Conflicts of Interests: None

REFERENCES

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LANGER’S AXILLARY ARCH AND ITS CLINICAL IMPLICATIONS