Multimedialna platforma wiedzy medycznej Internetowa Księgarnia Medyczna Kalendarium Konferencji
Folia Morphologica
MENU
Shortcuts Submit an article Author Guidelines (new) Ahead Of Print Reviewers 2023

open access

Vol 78, No 3 (2019)
Original article
Submitted: 2018-12-09
Accepted: 2018-12-23
Published online: 2019-01-18
View PDF Download PDF file
Get Citation

Accessory muscles of the anterior thoracic wall and axilla. Cadaveric, surgical and radiological incidence and clinical significance during breast and axillary surgery

S. Douvetzemis1, K. Natsis2, M. Piagkou1, M. Kostares1, T. Demesticha1, T. Troupis1
DOI: 10.5603/FM.a2019.0005
·
Pubmed: 30664230
·
Folia Morphol 2019;78(3):606-616.
Affiliations
  1. Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, Greece
  2. Department of Anatomy and Surgical Anatomy, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece

open access

Vol 78, No 3 (2019)
ORIGINAL ARTICLES
Submitted: 2018-12-09
Accepted: 2018-12-23
Published online: 2019-01-18

Abstract

Background: The present study aims to summarise the accessory muscles of the anterior thoracic wall and axilla that can be encountered during breast and axillary surgery and record their incidence and clinical significance. Moreover, the laterality of the atypical muscles is highlighted and possible gender dimorphism is referred. Accessory anterior thoracic wall muscles include: Langer’s axillary arch, sternalis muscle, chondrocoracoideus, chondroepitrochlearis, chondrofascialis, pectoralis minimus, pectoralis quartus and pectoralis intermedius.

Materials and methods: The anatomical, surgical and radiological literaturę has been reviewed and an anatomical study on 48 Greek adult cadavers was performed.

Results: Literature review revealed the existence of accessory muscles of the anterior thoracic wall and axilla that have a significant incidence that can be considered high and may, therefore, have clinical significance. For the most common of these muscles, which are axillary arch (Langer’s) and sternalis muscle, the cadaveric incidence is 10.30% and 7.67%, respectively. In the current cadaveric study, accessory thoracic wall muscles were identified in two cadavers; namely a bilateral sternalis muscle (incidence 2.08%) extending both to the anterior and posterior surface of the sternum and a left-sided chondrocoracoideus muscle (of Wood) (incidence 2.08%).

Conclusions: Despite the fact that accessory anterior thoracic wall and axillary muscles are considered to be rare, it is evident that the incidence of at least some of them is high enough to encounter them in clinical practice. Thus, clinicians’ awareness of these anatomical structures is advisable.

Abstract

Background: The present study aims to summarise the accessory muscles of the anterior thoracic wall and axilla that can be encountered during breast and axillary surgery and record their incidence and clinical significance. Moreover, the laterality of the atypical muscles is highlighted and possible gender dimorphism is referred. Accessory anterior thoracic wall muscles include: Langer’s axillary arch, sternalis muscle, chondrocoracoideus, chondroepitrochlearis, chondrofascialis, pectoralis minimus, pectoralis quartus and pectoralis intermedius.

Materials and methods: The anatomical, surgical and radiological literaturę has been reviewed and an anatomical study on 48 Greek adult cadavers was performed.

Results: Literature review revealed the existence of accessory muscles of the anterior thoracic wall and axilla that have a significant incidence that can be considered high and may, therefore, have clinical significance. For the most common of these muscles, which are axillary arch (Langer’s) and sternalis muscle, the cadaveric incidence is 10.30% and 7.67%, respectively. In the current cadaveric study, accessory thoracic wall muscles were identified in two cadavers; namely a bilateral sternalis muscle (incidence 2.08%) extending both to the anterior and posterior surface of the sternum and a left-sided chondrocoracoideus muscle (of Wood) (incidence 2.08%).

Conclusions: Despite the fact that accessory anterior thoracic wall and axillary muscles are considered to be rare, it is evident that the incidence of at least some of them is high enough to encounter them in clinical practice. Thus, clinicians’ awareness of these anatomical structures is advisable.

Full Text:

View PDF Download PDF file
Get Citation

Keywords

accessory muscle; sternalis; axillary arch; chondrocoracoideus; chondroepitrochlearis; chondrofascialis; pectoralis minimus; pectoralis quartus; pectoralis intermedius; variation

About this article
Title

Accessory muscles of the anterior thoracic wall and axilla. Cadaveric, surgical and radiological incidence and clinical significance during breast and axillary surgery

Journal

Folia Morphologica

Issue

Vol 78, No 3 (2019)

Article type

Original article

Pages

606-616

Published online

2019-01-18

Page views

2023

Article views/downloads

1771

DOI

10.5603/FM.a2019.0005

Pubmed

30664230

Bibliographic record

Folia Morphol 2019;78(3):606-616.

Keywords

accessory muscle
sternalis
axillary arch
chondrocoracoideus
chondroepitrochlearis
chondrofascialis
pectoralis minimus
pectoralis quartus
pectoralis intermedius
variation

Authors

S. Douvetzemis
K. Natsis
M. Piagkou
M. Kostares
T. Demesticha
T. Troupis

References (90)
  1. Adachi B. Beitrage zur anatomie der Japaner. Z Morphol Anthropol. 1909; 12: 261–312.
  2. Al Maksoud AM, Barsoum AK, Moneer MM. Langer's arch: a rare anomaly affects axillary lymphadenectomy. J Surg Case Rep. 2015; 2015(12).
    CrossRefPubMed
  3. Ando J, Kitamura T, Kuroki Y, et al. 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. 2010; 17(1): 3–8.
    CrossRefPubMed
  4. Arican RY, Coskun N, Sarikcioglu L, et al. Co-existence of the pectoralis quartus and pectoralis intermedius muscles. Morphologie. 2006; 90(290): 157–159.
    PubMed
  5. Barcia JM, Genovés JM. Chondrofascialis versus pectoralis quartus. Clin Anat. 2009; 22(8): 871–872.
    CrossRefPubMed
  6. Barlow R. The sternalis muscle in American whites and negroes. Anat Rec. 1935; 61(4): 413–426.
    CrossRef
  7. Bergman RA, Thompson SA, Afifi AK. Compen- dium of human anatomic variations. Urban and Schwarzenberg, Baltimore, Munich 1988.
  8. Bergman RA. Doubled pectoralis quartus, axillary arch, chondroepitrochlearis, and the twist of the tendon of pectoralis major. Anat Anz. 1991; 173(1): 23–26.
    PubMed
  9. Bergman RA. Anatomy atlases: illustrated encyclopedia of human anatomic variation. 2014. http://www.anatomyatlases.org/ (accessed 16 October 2015).
  10. Bertone VH, Ottone NE, Lo Tartaro M, et al. The morphology and clinical importance of the axillary arch. Folia Morphol. 2008; 67(4): 261–266.
    PubMed
  11. Besana-Ciani I, Greenall MJ. Langer’s axillary arch: anatomy, embryological features and surgical implications. Surgeon. 2005; 3(5): 325–327.
    CrossRefPubMed
  12. Bharambe V, Arole V. The axillary arch muscle (Langer′s muscle): Clinical importance. Med J DY Patil Univ. 2013; 6(3): 27–30.
    CrossRef
  13. Birmingham A. Homology and innervation of the achselbogen and pectoralis quartus, and the nature of the lateral cutaneous nerve of the thorax. J Anat Physiol. 1889; 23(Pt 2): 206–223.
    PubMed
  14. Bonastre V, Rodríguez-Niedenführ M, Choi D, et al. Coexistence of a pectoralis quartus muscle and an unusual axillary arch: case report and review. Clin Anat. 2002; 15(5): 366–370.
    CrossRefPubMed
  15. Bradley FM, Hoover HC, Hulka CA, et al. The sternalis muscle: an unusual normal finding seen on mammography. AJR Am J Roentgenol. 1996; 166(1): 33–36.
    CrossRefPubMed
  16. Bryce TH. Note on a Group of Varieties of the Pectoral Sheet of Muscle. J Anat Physiol. 1899; 34(Pt 1): 75–78.
    PubMed
  17. Chaijaroonkhanarak W, Amarttayakong P, Pannangrong W, et al. Incidence of the sternalis muscle in Northeastern Thais Srinagarind. Med J. 2013; 28: 62–65.
  18. Chêne G, Bouëdec GLe, Dauplat J. L'arche et la sentinelle: techniques chirurgicales de la lymphadénectomie axillaire sentinelle en présence du muscle pectoro-axillaire. Gynecol Obstet Fertil. 2007; 35(1): 25–29.
    CrossRef
  19. Chiba S, Suzuki T, Kasai T. A rare anomaly of the pectoralis major--the chondroepitrochlearis. Okajimas Folia Anat Jpn. 1983; 60(2-3): 175–185.
    PubMed
  20. Clark E. Congenital Variation of the Pectoral Muscles, with Report of a Case. J Anat Physiol. 1915; 49(Pt 2): 155–164.
    PubMed
  21. Clarys JP, Barbaix E, Van Rompaey H, et al. The muscular arch of the axilla revisited: its possible role in the thoracic outlet and shoulder instability syndromes. Man Ther. 1996; 1(3): 133–139.
    CrossRefPubMed
  22. Cunningham DJ. The musculus sternalis. J Anat Physiol. 1884; 18(Pt 2): 208–210.
    PubMed
  23. Daniels IR, della Rovere GQ. The axillary arch of Langer--the most common muscular variation in the axilla. Breast Cancer Res Treat. 2000; 59(1): 77–80.
    PubMed
  24. Del Sol M, Vásquez B. Anatomical and clinical considerations of the pectoralis tertius muscle in man. Int J Morphol. 2009; 27(3).
    CrossRef
  25. Demirpolat G, Oktay A, Bilgen I, et al. Mammographic features of the sternalis muscle. Diagn Interv Radiol. 2010; 16(4): 276–278.
    CrossRefPubMed
  26. Di Gennaro GL, Soncini G, Andrisano A, et al. The chondroepitrochlearis muscle: case report. Chir Organi Mov. 1998; 83(4): 419–423.
    PubMed
  27. Ebenezer DA, Rathinam BAD. Rare multiple variations in brachial plexus and related structures in the left upper limb of a Dravidian male cadaver. Anat Cell Biol. 2013; 46(2): 163–166.
    CrossRefPubMed
  28. Fabrizio PA, Hardy MA. An accessory muscle of the thoracic wall. Int J Anat Var. 2009; 2: 93–95.
  29. Flaherty G, O'Neill MN, Folan-Curran J. Case report: bilateral occurrence of a chondroepitrochlearis muscle. J Anat. 1999; 194 ( Pt 2): 313–315.
    CrossRefPubMed
  30. Ge Z, Tong Y, Zhu S, et al. Prevalence and variance of the sternalis muscle: a study in the Chinese population using multi-detector CT. Surg Radiol Anat. 2014; 36(3): 219–224.
    CrossRefPubMed
  31. Georgiev GP, Jelev L, Surchev L. Axillary arch in Bulgarian population: clinical significance of the arches. Clin Anat. 2007; 20(3): 286–291.
    CrossRefPubMed
  32. Haninec P, Tomás R, Kaiser R, et al. Development and clinical significance of the musculus dorsoepitrochlearis in men. Clin Anat. 2009; 22(4): 481–488.
    CrossRefPubMed
  33. Harish K, Gopinath KS. Sternalis muscle: importance in surgery of the breast. Surg Radiol Anat. 2003; 25(3-4): 311–314.
    CrossRefPubMed
  34. Huntington GS. The derivation and significance of certain supernumerary muscles of the pectoral region. J Anat Physiol. 1904; 39(Pt 1): 1–54.
    PubMed
  35. Ishii N, Shimizu Y, Ando J, et al. Complete coverage of a tissue expander by a musculofascial pocket including the sternalis muscle during breast reconstruction. Arch Plast Surg. 2018; 45(1): 89–90.
    CrossRefPubMed
  36. Jaijesh P. Unilateral appearance of a chondro-epitrochlearis muscle-a case report. Indian J Plast Surg. 2005; 38(2): 164.
    CrossRef
  37. Jelev L, Georgiev G, Surchev L. The sternalis muscle in the Bulgarian population: classification of sternales. J Anat. 2001; 199(Pt 3): 359–363.
    CrossRefPubMed
  38. Jelev L, Georgiev GP, Surchev L. Axillary arch in human: common morphology and variety. Definition of "clinical" axillary arch and its classification. Ann Anat. 2007; 189(5): 473–481.
    CrossRefPubMed
  39. Jeng H, Su SJ. The sternalis muscle: an uncommon anatomical variant among Taiwanese. J Anat. 1998; 193 ( Pt 2): 287–288.
    CrossRefPubMed
  40. Kalaycioglu A, Gümüsalan Y, Ozan H. Anomalous insertional slip of latissimus dorsi muscle: arcus axillaris. Surg Radiol Anat. 1998; 20(1): 73–75.
    PubMed
  41. Kanaka S, Pulipati A, Gaikwad M. Axillary arch and its relations — a rare case report. Int J Biol Med Res. 2012; 3: 2277–2779.
  42. Karanlik H, Fathalizadeh A, Ilhan B, et al. Axillary arch may affect axillary lymphadenectomy. Breast Care. 2013; 8(6): 424–427.
    CrossRefPubMed
  43. Kasai T, Chiba S. [True nature of the muscular arch of the axilla and its nerve supply (author's transl)]. Kaibogaku Zasshi. 1977; 52(5): 309–336.
    PubMed
  44. Katara P, Chauhan S, Arora R, et al. A unilateral rectus sternalis muscle: rare but normal anatomical variant of anterior chest wall musculature. J Clin Diagn Res. 2013; 7(12): 2665–2667.
    CrossRefPubMed
  45. Kataria K, Srivastava A, Mandal A. Axillary arch muscle: a case report. Eur J Anat. 2013; 17: 259–261.
  46. Khan UD. Use of the rectus sternalis in augmentation mammoplasty: case report and literature search. Aesthetic Plast Surg. 2008; 32(1): 21–24.
    CrossRefPubMed
  47. Khan A, Chakravorty A, Gui GPH. In vivo study of the surgical anatomy of the axilla. Br J Surg. 2012; 99(6): 871–877.
    CrossRefPubMed
  48. Knott JF. Muscular anomalies. J Anat Physiol. 1880; 15(Pt 1): 139–140.
    PubMed
  49. Kutiyanawala MA, Stotter A, Windle R. Anatomical variants during axillary dissection. Br J Surg. 1998; 85(3): 393–394.
    CrossRefPubMed
  50. Lama P, Potu BK, Bhat KMR. Chondrohumeralis and axillary arch of Langer: a rare combination of variant muscles with unique insertion. Rom J Morphol Embryol. 2010; 51(2): 395–397.
    PubMed
  51. Lin C. Contracture of the chondroepitrochlearis and the axillary arch muscles. A case report. J Bone Joint Surg Am. 1988; 70(9): 1404–1406.
    PubMed
  52. Locchi R. Reserches d’anatomie ethnique sur le ‘musculus sternalis’ Comptes rendus de 1’Associations des Anatomistes. 1930; 25: 212.
  53. Londhe SR, Jadhav AS, Koti MN. Unilateral rectus stermalis muscle a case presentation. Anat Karnataka. 2010; 4: 51–53.
  54. Mérida-Velasco JR, Rodríguez Vázquez JF, Mérida Velasco JA, et al. Axillary arch: potential cause of neurovascular compression syndrome. Clin Anat. 2003; 16(6): 514–519.
    CrossRefPubMed
  55. Miguel M, Llusá M, Ortiz JC, et al. The axillopectoral muscle (of Langer): report of three cases. Surg Radiol Anat. 2001; 23(5): 341–343.
    PubMed
  56. Mori M. Statistics on the musculature of the Japanese. Okajimas Folia Anat Jpn. 1964; 40: 195–300.
    PubMed
  57. Natsis K, Vlasis K, Totlis T, et al. Abnormal muscles that may affect axillary lymphadenectomy: surgical anatomy. Breast Cancer Res Treat. 2010; 120(1): 77–82.
    CrossRefPubMed
  58. Natsis K, Totlis T, Sofidis G. Chondroepitrochlearis: an abnormal muscle that may affect axillary lymphadenectomy. ANZ J Surg. 2012; 82(4): 286–287.
    CrossRef
  59. O'Neill MN, Folan-Curran J. Case report: bilateral sternalis muscles with a bilateral pectoralis major anomaly. J Anat. 1998; 193 ( Pt 2): 289–292.
    CrossRefPubMed
  60. Perrin JB. Notes on some variations of the pectoralis major, with its associate muscles. J Anat Physiol. 1871; 5(Pt 2): 233–420.19.
    PubMed
  61. Petrasek AJ, Semple JL, McCready DR. The surgical and oncologic significance of the axillary arch during axillary lymphadenectomy. Can J Surg. 1997; 40(1): 44–47.
    PubMed
  62. Rai R, Ranade A, Prabhu L, et al. Unilateral Pectoralis Minimus Muscle: A Case Report. Int J Morphol. 2008; 26(1): 27–29.
    CrossRef
  63. Raikos A, Paraskevas GK, Yusuf F, et al. Sternalis muscle: a new crossed subtype, classification, and surgical applications. Ann Plast Surg. 2011; 67(6): 646–648.
    CrossRefPubMed
  64. Ridgway PF, Collins AM, McCready DR. The surgical importance of an axillary arch in sentinel node biopsy. Surg Radiol Anat. 2011; 33(2): 147–149.
    CrossRefPubMed
  65. Rizk E, Harbaugh K. The muscular axillary arch: an anatomic study and clinical considerations. Neurosurgery. 2008; 63(4 Suppl 2): 316–319.
    CrossRefPubMed
  66. Sachatello CR. The axillopectoral muscle (Langer's axillary arch): a cause of axillary vein obstruction. Surgery. 1977; 81(5): 610–612.
    PubMed
  67. Saeed M, Murshid KR, Rufai AA, et al. Sternalis. An anatomic variant of chest wall musculature. Saudi Med J. 2002; 23(10): 1214–1221; Erratum in: Saudi Med J. 2002; 23(12): 1561. Saudi Med J 2006; 27(6): 914.
    PubMed
  68. Samuel VP, Vollala VR. Unusual pectoralis major muscle: the chondroepitrochlearis. Anat Sci Int. 2008; 83(4): 277–279.
    CrossRefPubMed
  69. Sarikcioglu L, Yildirim FB, Chiba S. Unilateral occurrence of a chondroepitrochlearis muscle. Clin Anat. 2004; 17(3): 272–275.
    CrossRefPubMed
  70. Sasmal PK, Meher S, Mishra TS, et al. Sternalis muscle: an unexpected finding during mastectomy. Case Rep Surg. 2015; 2015: 723198.
    CrossRefPubMed
  71. Sawada M, Ishibashi Y, Suzuki T, et al. Case report on the pectoralis quadratus and the pectoralis intermedius muscles. Acta Anat Nippon. 1991; 66: 99–105.
  72. Serpell JW, Baum M. Significance of 'Langer's axillary arch' in axillary dissection. Aust N Z J Surg. 1991; 61(4): 310–312.
    PubMed
  73. Shiotani M, Higuchi T, Yoshimura N, et al. The sternalis muscle: radiologic findings on MDCT. Jpn J Radiol. 2012; 30(9): 729–734.
    CrossRefPubMed
  74. Snosek M, Tubbs RS, Loukas M. Sternalis muscle, what every anatomist and clinician should know. Clin Anat. 2014; 27(6): 866–890.
    CrossRefPubMed
  75. Spinner RJ, Carmichael SW, Spinner M. Infraclavicular ulnar nerve entrapment due to a chondroepitrochlearis muscle. J Hand Surg Br. 1991; 16(3): 315–317.
    PubMed
  76. Takafuji T, Igarashi J, Kanbayashi T, et al. [The muscular arch of the axilla and its nerve supply in Japanese adults]. Kaibogaku Zasshi. 1991; 66(6): 511–523.
    PubMed
  77. Taterra D, Henry BM, Zarzecki MP, et al. Prevalence and anatomy of the axillary arch and its implications in surgical practice: A meta-analysis. Surgeon. 2019; 17(1): 43–51.
    CrossRefPubMed
  78. Totlis T, Iosifidou R, Pavlidou F, et al. Complicated axillary lymphadenectomy due to a pectoralis quartus muscle. Chirurgia (Bucur). 2012; 107(3): 397–398.
    PubMed
  79. Tountas CP, Bergman RA. Anatomic variations of the upper extremity. Churchill Livingstone, New York. 1993: 79–81.
  80. Turgut HB, Anil A, Peker T, et al. Insertion abnormality of bilateral pectoralis minimus. Surg Radiol Anat. 2000; 22(1): 55–57.
    PubMed
  81. Turgut HB, Peker T, Gülekon N, et al. Axillopectoral muscle (Langer's muscle). Clin Anat. 2005; 18(3): 220–223.
    CrossRefPubMed
  82. Turki MA, Adds PJ. Langer's axillary arch: a rare variant, and prevalence among Caucasians. Folia Morphol. 2017; 76(3): 536–539.
    CrossRefPubMed
  83. Turner W. On the Musculus Sternalis. J Anat Physiol. 1867; 1(2): 246–253.
    PubMed
  84. Upasna Kumar A, Singh B, Kaushal S. Muscular variations during axillary dissection: a clinical study in fifty patients. Niger J Surg. 2015; 21(1): 60–62.
    CrossRefPubMed
  85. Van Hoof T, Vangestel C, Forward M, et al. The impact of muscular variation on the neurodynamic test for the median nerve in a healthy population with langer's axillary arch. J Manipulative Physiol Ther. 2008; 31(6): 474–483.
    CrossRef
  86. Venieratos D, Samolis A, Piagkou M, et al. The chondrocoracoideus muscle: A rare anatomical variant of the pectoral area. Acta Med Acad. 2017; 46(2): 155–161.
    CrossRefPubMed
  87. Voto SJ, Weiner DS. The chondroepitrochlearis muscle. J Pediatr Orthop. 1987; 7(2): 213–214.
    PubMed
  88. Wallace D. Nerve supply of musculus sternalis. J Anat Physiol. 1886; 21(Pt 1): 153–154.
    PubMed
  89. Wood J. Variations in human myology observed during the Winter Session of 1865–6 at King’s College, London. Proc Royal Soc. 1866; 15: 229–244.
  90. Young Lee B, Young Byun J, Hee Kim H, et al. The sternalis muscles: incidence and imaging findings on MDCT. J Thorac Imaging. 2006; 21(3): 179–183.
    CrossRefPubMed

Regulations

Important: This website uses cookies. More >>

The cookies allow us to identify your computer and find out details about your last visit. They remembering whether you've visited the site before, so that you remain logged in - or to help us work out how many new website visitors we get each month. Most internet browsers accept cookies automatically, but you can change the settings of your browser to erase cookies or prevent automatic acceptance if you prefer.

By VM Media Group sp. z o.o., Grupa Via Medica, Świętokrzyska 73, 80–180 Gdańsk, Poland

tel.: +48 58 320 94 94, faks: +48 58 320 94 60, e-mail: viamedica@viamedica.pl