Austin J Anat. 2014;1(4): 1020.
Department of Systematic Anatomy, Medical University Vienna, Austria
*Corresponding author: Hirtler L, Department of Systematic Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Währinger straße 13, 1090 Vienna, Austria
Received: August 27, 2014; Accepted: September 24, 2014; Published: September 29, 2014
Langer’s axillary arch is an important anatomical variant of the shoulder region, connecting the latissimus dorsi and the pectoralis major muscles. Due to its frequency, clinicians should be aware of this variant as misidentifications could lead to severe complications in patient treatment.
The presented axillary arch was identified in a 67 years old specimen. Its innervation by the lateral pectoral nerve and blood supply by the subscapular artery could be preserved.
In conclusion, this case report and literature overview point out a clinical important anatomical variant, Langer’s axillary arch. Its misidentification can lead to wrong diagnoses and massive surgical complications, which could easily be avoided by intimate anatomical knowledge of the axillar region and its most frequent variants.
Keywords: Langer’s axillary arch; Anatomical variant; Shoulder region; Lateral pectoral nerve; Subscapular artery; Latissimus dorsi muscle; Pectoralis major muscle
Langer’s axillary arch is an important anatomical variant of the shoulder region, connecting the latissimus dorsi muscle and the pectoralis major muscle. With a frequency of 7-8 % [1-9] it is a variant seen often in this region. However, this frequency range is depending on the population. Numbers can be found in literature between 1.7% in the Turkish population  and 43.8% in the Chinese population . Cases of this anatomical variant reported during surgery are even less frequent  ranging from 0.25% to 4.3% [8, 13-15].
The history of the axillary arch is already a long one. First described in 1783 by Bugnone  and in 1793 by Ramsay [5,17], this variant became of greater interest after the account of Langer in 1846 [18,19]. Nevertheless one should mention, that Bugnone  and Ramsay [5,17] both described a muscular variation, and that Langer [18,19] mentions a fibrous arch without any muscular fibres. However, nowadays “Langer’s axillary arch”, as mentioned first by Testut  and now known by this name throughout literature, is the term for any variant coursing between the latissimus dorsi muscle and the pectoralis major muscle.
Jelev  summarized the three main characteristics of a typical axillary arch in his literature review:
- The axillary arch has a constant origin from the latissimus dorsi muscle.
- The axillary arch inserts into structures around the anterosuperior part of the humerus.
- The axillary arch crosses the axillar neurovascular bundle from dorsomedial to ventrolateral.
The aim of this report was, to show the high variability of this anatomical variant, to emphasise the importance of its correct identification and to summarize existing literature on muscular variants in this shoulder by an example of a muscular axillary arch found during dissection.
During the dissection course for our medical students at the anatomical institute of the medical university, this variant was observed in a 67 years old male specimen. The specimen was previously prepared for dissection by perfusion with a formol-phenol-solution.
The muscular slip of the axillary arch was identified in a right shoulder, running from the latissimus dorsi muscle towards the insertion of the pectoralis major muscle at the crest of the greater tubercle of the humerus. There it inserted distally to the insertion of the pectoralis major muscle directly into the humerus (Figure 1).
Figure 1: (a) photograph of the right shoulder of the specimen, (b) sketch of the same specimen showing the localization of Langer’s axillary arch (LAA) and the surrounding muscles: pectoralis major muscle (PMa), latissimus dorsi muscle (LD), pectoralis minor muscle (PMi), coracobrachialis muscle (CB), biceps brachii muscle (BB), triceps brachii muscle (TB), deltoideus muscle (DM).
The axillary arch originated from the latissimus dorsi muscle via a tendinous intersection (Figure 2), no continuous muscle fibres from the latissimus dorsi muscle into the axillary arch were observed.
Figure 2: (a) photograph of the origin of Langer’s axillary arch, (b) sketch of the same section showing the attachment of Langer’s axillary arch (LAA) through the tendinous intersection (stars) at the latissimus dorsi muscle. Blood supply was derived from the subscapular artery (SCA). Teres major muscle (TM).
Innervation of this muscular slip was provided by the lateral pectoral nerve. Also the separated vascularization of the axillary arch was preserved, originating from the subscapular artery (Figure 2).
Discussing Langer’s axillary arch, one has first to recapitulate the muscular anatomy of the shoulder region and get an impression of all the possible muscular variants in this region. The muscle mass of the shoulder built of three groups, the scapulohumeral group (supraspinatus, infraspinatus, teres minor, subscapularis, deltoideus), the axiohumeral group (pectoralis major, latissimus dorsi, pectoralis minor) and the axioscapular group (serratus anterior, rhomboideus major and minor, levator scapulae, trapezius) . Biceps brachii, tricpes brachii, brachialis and coracobrachialis complete this enumeration.
In all those muscles, anatomical variants have been described in literature and should be mentioned in short in the following paragraphs.
Variations described for the biceps brachii muscle only affect the proximal origin of the muscle. It can show different numbers of heads, those arising from different parts of the scapula, the humerus or the soft tissue of the upper arm and shoulder. There are no variations described at the insertion site at the radial tuberositas described [1,23,5,6,24].
For the brachialis muscle, there are variations mentioned concerning the complete division into two bellies by the biceps brachialis or a fibrous arcade between radius and ulna and different insertion sites at the forearm or its total absence [1,5,24].
Similar to the biceps brachii muscle, the triceps brachii muscle also shows a frequent variation of its heads - usually an additional one originating from the scapula, the coracoid process, the glenoid capsule or the humerus - or connections with muscles in the vicinity of its origin, for example the subscapularis muscle or the latissimus dorsi muscle. The most frequent variation (m. epitrochleo-olecraneum sive epitrochleoanconeus) with 25 % of dissected bodies described by Bergman and 26,5 to 34 % of dissected body’s described by Le Double is a musculotendinous arch crossing from the medial epicondyle over the ulnar nerve towards the olecranon process [1,5,25-27].
The deltoid muscle is overall featured as a reliable structure with very few variations. Exceptions are the total separation of the muscular part of the deltoid muscle or their absence . Only Le Double, Rauber-Kopsch and Bergman describe interconnections with the pectoralis major, the trapezius the infraspinatus, the latissimus dorsi, the brachioradialis and the brachialis muscles. The fascicle towards the brachialis muscle can present itself crossing the biceps brachii muscle to its medial side and traversing the neurovascular bundle to insert near the medial epicondyle [1,28,5].
The major variations of the coracobrachialis muscle are the possible formation of a muscle with a more distal (m. coracobrachialis longus) or proximal (m. coracobrachialis brevis) insertion. The insertion of the coracobrachialis brevis muscle reaches only the humeral capsule of the shoulder or its vicinity [1,29,24,30]. The insertion of the coracobrachialis longus muscle can get as far as the medial epicondyle of the humerus [1,29,5].
The pectoralis major muscle - apart from variations of his origin - can give off a musculotendinous bundle towards the brachial fascia, the joint capsule of the shoulder, the coracobrachial muscle and the latissimus dorsi muscle (Langer’s axillar arch) [23,29,6,31,24]. A strand from the insertion of the pectoralis major muscle to the medial intermuscular septum of the arm is called chondrofascial muscle of Macallister and a strand arising from one or more ribs inserting into the medial intermuscular septum or the medial epicondyle of the humerus is named costo-epitrochlearis, chondro-epitrochlearis or chondro-humeralis muscle and described by Le Double in 12 to 20 % of the dissected bodies [1,29,5,31]. This muscle fascicle, passing the inferior margin of the pectoralis major, has to cross the large nerves and vessels at the medial border of the biceps brachii to get to the medial epicondyle [32,33]. Although the high incidence stated by Le Double this should be regarded rather critically - many authors doubt this high number of cases considering the few documentations in literature . Natsis et al.  for example didn’t find this variation at all in a study of 107 anatomic specimens. The descriptions of Wood [25,26,35,36,37,38,30] are a perfect example for the high incidence described by Le Double, considering that according to him every epigastric slip running in direction of the arm equalized the chondro-epitrochlearis of apes and monkeys and was therefore added to the list .
Apart from variations of its origin, the latissimus dorsi frequently has an additional origin at the inferior angle of the scapula. In conjunction with the pectoralis major, it forms Langer’s axillary arch. In 5 % of dissected body’s an additional musculotendinous strand towards the medial epicondyle can be found - the dorsoepitrochlearis, anconeus longus or latissimus condylaris muscle [1,23,29,5,24,37].
Throughout literature, the described muscular variant running from the latissimus dorsi muscle towards the pectoralis major muscle is known by several names: arcus axillaris [40,10,41], Achselbogen [2,23,42-47], axillary arch [48-52,9], arc axillaire [5,20,53].
As described previously, the typical axillary arch shows three characteristics (constant origin from the latissimus dorsi muscle, insertion into structures around the anterosuperior part of the humerus, crossing over the axillar neurovascular bundle from dorsomedial to ventrolateral) .
There exists however some difference in the characterization of the axillary arch. The primary description of this variant by Bugnone  and Ramsay [5,17] was a muscular one. In contrast, Langer [18,19] described a fibrous or fascial variant. This Eisler  took into consideration and made the following differentiation: A fascial axillary arch was defined as a fascial thickening of the medial border of the axillar fascia coursing between the pectoralis major muscle and the latissimus dorsi muscle. A muscular axillary was further subdivided into a latissimus axillary arch and a pectoralis axillary arch, depending on the course of the muscular fibres and their attachments.
There are several forms of origins of the axillary arch described in literature: direct continuation of the muscular fibres of the latissimus dorsi muscle [7,12,54-60], origin at the latissimus dorsi tendon [54,61,62,56,51,7,45,59], a combination of direct muscular fibres of the latissimus dorsi muscle and small tendinous intersections of the arch [54,62,46,59]. Looking at the case presented in this study, the axillary arch showed a clear origin solely by tendinous intersection from the muscular bulk of the latissimus dorsi muscle.
The possible locations of the insertions of the axillary arch are even more numerous: attached to the deep surface of the tendon of the pectoralis major muscle [63,54,62,7,57,46,41,24], to the pectoralis major itself , to the fascia of the coracobrachialis muscle [1,54,10,7,52], to the fascia covering the biceps brachii muscle [41,58,27], to the long head of the biceps brachii muscle , to the coracoid process [1,2,57,20,64,24,26], to the pectoralis minor muscle [1,5] and to the axillary fascia [1,18,19,5]. In described case, the muscular slip inserted distally to the insertion of the pectoralis major muscle at the crest of the greater tubercle of the humerus directly to the bone (Figure 1). This was also not described up to now in existing literature.
The innervation of the axillary arch is also quite variable and mainly based on the following three nerves: the lateral pectoral nerve [65,42,14,66,67,46,68,69,47], the medial pectoral nerve [56,14,7,66,68,69,70,71], the thoracodorsal nerve [72,10,7,57,70,73,59,60]. In the presented case the innervation of the axillary arch was derived from the lateral pectoral nerve.
There is however confusion, which nerve most frequently innervates the axillary arch whether it is the lateral pectoral nerve [74,65,73,42,46], the medial pectoral nerve [55,74,71] or the thoracodorsal nerve .
But this innervation could give some clue as to the embryological origin of the axillary arch [42,5,31,78] whether it originates from an incomplete dorsoepitrochlearis muscle, or it is a homologue of the pectoralis quartus muscle, or a remnant of panniculus carnosus, or a remnant of the superficial common layer of the latissimus dorsi muscle and the pectoralis major muscle are the hypotheses mentioned in literature. Especially the last theory seems interesting as Hollinshead and Wilson propose to identify the embryological origin of this variant based on the respective innervation: coming from the pectoral nerves it is probably derived from the pectoralis major muscle , coming from the thoracodorsal nerve it is probably originating from the latissimus dorsi muscle . On the other side, one has also to report on the work of Shinohara [79,80, who strictly refutes such line of hypothesis of muscle origins and rather links the development of a muscle and its nerve to differential expression of genes by their positions on the anterior-posterior axis. He also argues that the migration patterns of a muscle and its corresponding nerve are not due to their respective origin but rather are regulated by the gene encoding of the nerve cells, the myogenic cells and the surrounding tissue. Reading the mentioned hypotheses, it is clear that the last word on muscle and motoric nerve development is not yet spoken and needs further research in the future.
Concerning the blood supply, there are only two patterns described hitherto–derived from the lateral thoracic vessels  and, as in our case, coming from the subscapular artery .
Knowledge of this particular variant is especially important in clinical practice and could lead to several complications in patient treatment. Looking at lymph nodes, the muscular bulk of the axillary arch could possibly be mistaken for a tumor [50,69], or the palpation of the lymph nodes could be made more difficult [74,3,82]. Also in imaging procedures, these lymph nodes could be obscured by the muscle [74,74,82]. But also some axillar structures could be entrapped, leading to the impingement of the brachial plexus, to a hyperabduction syndrome [7,20], to a costoclavicular compression syndrome and to axillary vein entrapment [83,84,68]. But also in axillary surgery  or in breast reconstruction using a latissimus dorsi musculocutaneous flap this anatomical variant could lead to complications due to its close relationship to the neurovascular structures of the axilla [81,85].
Due to these possible complications, correct identification of Langer’s axillary arch is very important in clinical practice. In patients with blue discolorations of the arm and complaining of swelling in the axilla starting especially when physically active (e.g. swimmers) this muscular variant should be kept in mind [77,68]. The symptoms should disappear in adduction, as the arch becomes taut in shoulder abduction and elevation with concomitant compression of the axillary neurovascular bundle [83,61,68].
Sometimes this muscle mass is more visible than palpable , but mostly one sees a visible axillar fullness  and the muscle should be always better palpable in shoulder abduction and can be absent in adduction [61,12,3,77,86,69,15,87]. Also the use of several imaging techniques like echography, mammography, computed tomography and magnetic resonance imaging have been described in literature [83,61,3,88], but here also the axillary arch seems to be almost only visible in abduction and could be easily missed nowadays by the adducted position of the patients during the respective imaging procedure.
Especially when Langer’s axillary arch develops a contracture, the patients complain of severe difficulties in elevating or even moving their arms. But in all symptomatic cases, transection of this muscular slip cures the problem [48, 68,62].
In conclusion, this case presentation and literature overview point out a clinical important anatomical variant, Langer’s axillary arch. Its misidentification can lead to wrong diagnoses and massive surgical complications, which could easily be avoided by intimate anatomical knowledge of the axillar region and its most frequent anatomical variants.
- Bergman RA. Compendium of human anatomic variation: text, atlas, and world literature. Urban & Schwarzenberg. 1988.
- Eisler P. Die Muskeln des Stammes: Gustav Fischer. 1912.
- Guy MS, Sandhu SK, Gowdy JM, Cartier CC, Adams JH. MRI of the axillary arch muscle: prevalence, anatomic relations, and potential consequences. AJR Am J Roentgenol. 2011; 196: W52-57.
- Haagensen CD. Diseases of the breast. Philadelphia: Sauders. 1956. 751.
- Le Double A-F. Traité des variations du système musculaire de l'homme et leur signification au point de vue de l'anthropologie zoologique, Tome Second. Paris: Librairie C. Reinwald, Schleicher Frères. 1897.
- Meckel JF. Handbuch der menschlichen Anatomie: Buchhandlung des Hallischen Waisenhaus; 1816.
- Mérida-Velasco JR, Rodríguez Vázquez JF, Mérida Velasco JA, Sobrado Pérez J, Jiménez Collado J. Axillary arch: potential cause of neurovascular compression syndrome. Clin Anat. 2003; 16: 514-519.
- Rizk E, Harbaugh K. The muscular axillary arch: an anatomic study and clinical considerations. Neurosurgery. 2008; 63: 316-319.
- Standring S. Gray's Anatomy: The Anatomical Basis of Clinical Practice: Elsevier Health Sciences UK. 2008.
- Kalaycioglu A, Gümüsalan Y, Ozan H. Anomalous insertional slip of latissimus dorsi muscle: arcus axillaris. Surg Radiol Anat. 1998; 20: 73-75.
- Wagenseil F. Muskelbefunde bei Chinesen. 4 Sonderheft (Verhandlungen der Gesellschaft für physische Anthropologie, Band 2). Anthropol Anz. 1927: 42 - 51.
- Georgiev GP, Jelev L, Surchev L. Axillary arch in Bulgarian population: clinical significance of the arches. Clin Anat. 2007; 20: 286-291.
- Daniels IR, della Rovere GQ. The axillary arch of Langer--the most common muscular variation in the axilla. Breast Cancer Res Treat. 2000; 59: 77-80.
- Le Bouedec G, Dauplat J, Guillot M, Vanneuville G. [The axillopectoral muscle]. J Chir (Paris). 1993; 130: 66-69.
- Serpell JW, Baum M. Significance of 'Langer's axillary arch' in axillary dissection. Aust N Z J Surg. 1991; 61: 310-312.
- Pitzorno H. Contributo alla morfologia dell'arco ascellare musculare di Langer. Arch Ital Anat Embryol. 1911; 10: 129-144.
- Ramsay A. An account of unusual conformation of some muscles and vessels. Edinburgh Med Surg J. 1812; 8: 281-283.
- Langer C. Zur Anatomie des Musculus latissimus dorsi. Österr Med Wochenschrift. 1846; 15: 454 - 458.
- Langer C. Zur Anatomie des Musculus latissimus dorsi (Schluss). Österr Med Wochenschrift. 1846; 16: 486-492.
- Testut L. Les Anomalies Musculaires chez l'Homme Expliquées par l'Anatomie Comparée et leur Importance en Anthropologie. Paris: Masson; 1884.
- 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: 473-481.
- Inman VT, Saunders JB, Abbott LC. Observations of the function of the shoulder joint. 1944. Clin Orthop Relat Res. 1996; 3-12.
- Gegenbaur G. Lehrbuch der Anatomie des Menschen: Wilhelm Englemann. 1888.
- Von Lanz T, Wachsmuth W. Lanz / Wachsmuth Praktische Anatomie. Arm: Ein Lehr- und Hilfsbuch der anatomischen Grundlagen ärztlichen Handelns. Springer. 2003.
- Amiel D, Kleiner JB, Roux RD, Harwood FL, Akeson WH. The phenomenon of "ligamentization": anterior cruciate ligament reconstruction with autogenous patellar tendon. J Orthop Res. 1986; 4: 162-172.
- Wood J. On some Varieties in Human Myology. Proc Roy Soc Lon. 1863-1864; 13: 229-303.
- Wood J. Variations in Human Myology Observed during the Winter Session of 1865-1866 at King's College, London. Proc Roy Soc Lon. 1866-1867; 15: 229-244.
- Kopsch F, Rauber AA. Rauber-Kopsch Lehrbuch und Atlas der Anatomie des Menschen: Allgemeines Skeletsystem Muskelsystem Gefa (~ssystem: Thieme; 1955.
- Krause W. Handbuch der menschlichen Anatomie: Hahn'sche Hofbuchhandlung. 1880.
- Wood J. Variations in Human Myology Observed during the Winter Session of 1867-68 at King's College, London. Proc Roy Soc Lon. 1867-1868; 16: 483-525.
- Perrin JB. Notes on some Variations of the Pectoralis Major, with its Associate Muscles. J Anat Physiol. 1871; 5: 233-420.
- Flaherty G, O'Neill MN, Folan-Curran J. Case report: bilateral occurrence of a chondroepitrochlearis muscle. J Anat. 1999; 194: 313-315.
- Hyrtl J. Lehrbuch der Anatomie des Menschen mit Rücksicht auf physiologische Begründung und praktische Anwendung: Braumüller. 1863.
- Natsis K, Vlasis K, Totlis T, Paraskevas G, Noussios G, Skandalakis P. Abnormal muscles that may affect axillary lymphadenectomy: surgical anatomy. Breast Cancer Res Treat. 2010; 120: 77-82.
- Wood J. Additional Varieties in Human Myology. Proc Roy Soc Lon. 1865; 14: 379-392.
- Wood J. Variations in Human Myology Observed during the Winter Session of 1866-67 at King's College, London. Proc Roy Soc Lon. 1866-1867; 15: 518-546.
- Wood J. On Human Muscular Variations and their Relation to Comparative Anatomy. J Anat Physiol. 1867; 1: 44-59.
- LANDRY SO Jr. The phylogenetic significance of the chondro-epitrochlearis muscle and its accompanying pectoral abnormalities. J Anat. 1958; 92: 57-61.
- Jouffroy FK. Musculature des members. In: Grassé PP, editor. Traité de Zoologie, Anatomie Systématique, Biologie, Mammifères. Tome XVI, Fasc. III. Paris: Masson et Cie. Libr. de l'Academie de Médecine. 1971.
- Schramm U, von Keyserlingk DG. [Latissimus arc of the upper arm]. Anat Anz. 1984; 156: 75-78.
- 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: 206-223.
- Gehy K. Neue Beiträge zur Geschichte des Achselbogens des Menschen, eines Rudimentes des Panniculus der Mammalier. Morphol Jahrb. 1903; 31: 446-452.
- Ruge G. Der Hautrumpfmuskel der Säugetiere - Der M. sternalis und der Achselbogen des Menschen. Gegenbaurs Morphol Jahrb. 1905; 33: 379-531.
- Ruge G. Anleitungen zu den Präparierübungen an der Menschlichen Leiche. 4 edn. Leipzig: Verlag von Wilhelm Engelmann. 1908.
- Ruge G. Ein Rest des Haut-Rumpf-Muskels in der Achselgegend des Menschen - "Achselbogen". Gegenbaurs Morphol Jahrb. 1910; 41: 519-538.
- Tobler L. Der Achselbogen des Menschen, ein Rudiment des Panniculus carnosus der Mammalier. Morphol Jahrb. 1902; 30: 453-507.
- Babu ED, Khashaba A. Axillary arch and its implications in axillary dissection--review. Int J Clin Pract. 2000; 54: 524-525.
- Boileau Grant JC, Basmajian JV. Grant's Method of Anatomy. 7th edn. Baltimore: The Williams & Wilkins Company. 1965.
- Bonastre V, Rodríguez-Niedenführ M, Choi D, Sa˝udo JR. Coexistence of a pectoralis quartus muscle and an unusual axillary arch: case report and review. Clin Anat. 2002; 15: 366-370.
- Marciniak T, Serafin K. On the innervation of the axillary arch by the n. intercostobrachialis. Folia Morphol. 1929; 1: 23-35.
- Smith RA Jr, Cummings JP. The axillary arch: anatomy and suggested clinical manifestations. J Orthop Sports Phys Ther. 2006; 36: 425-429.
- Testut L, Jacob O. Traité d'Anatomie Topographique avec Applications Médico-Chirurgicales. Tome II. Abdomen, Bassin, Membres. 3 (edn). Paris: Octave Doin et fils. 1914.
- Bluntschli H. Über die Beteiligung des Musculus latissimus dorsi an Achselbogenbildungen beim Menschen. Gegenbaurs Morphol Jahrb. 1910; 41: 539-557.
- Dharap A. An unusually medial axillary arch muscle. J Anat. 1994; 184: 639-641.
- Kasai T, Chiba S. [True nature of the muscular arch of the axilla and its nerve supply (author's transl)]. Kaibogaku Zasshi. 1977; 52: 309-336.
- Miguel M, Llusá M, Ortiz JC, Porta N, Lorente M, Götzens V, et al. The axillopectoral muscle (of Langer): report of three cases. Surg Radiol Anat. 2001; 23: 341-343.
- Ucerler H, Ikiz ZA, Pinan Y. Clinical importance of the muscular arch of the axilla (axillopectoral muscle, Langer's axillary arch). Acta Chir Belg. 2005; 105: 326-328.
- Uzmansel D, Kurto─člu Z, Kara A, OztÃrk NC. Frequency, anatomical properties and innervation of axillary arch and its relation to the brachial plexus in human fetuses. Surg Radiol Anat. 2010; 32: 859-863.
- Yüksel M, Yüksel E, Sürücü S. An axillary arch. Clin Anat. 1996; 9: 252-254.
- Clarys JP, Barbaix E, Van Rompaey H, Caboor D, Van Roy P. The muscular arch of the axilla revisited: its possible role in the thoracic outlet and shoulder instability syndromes. Man Ther. 1996; 1: 133-139.
- Dbalý J. [A case of bilateral occurence of the muscular axillary arch]. Anat Anz. 1975; 137: 75-78.
- Afshar M, Golalipour MJ. Innervation of muscular axillary arch by a branch from pectoral loop. Int J Morphol. 2005; 23: 279-280.
- Vare AM, Indurkar GM. Some anomalous findings in the axillary musculature. J Anat Soc Ind. 1965; 14: 34-36.
- Bascho P. Beobachtung eines Restes des Hautrumpfmuskels beim Menschen, Pars thoracalis lateralis desselben. Gegenbaurs Morphol Jahrb. 1905; 33: 374-378.
- Paturet G. Traite´ d'anatomie humaine. Tome I. Ostépologie, Arthrologie, Myologie. Paris: Masson; 1951.
- Princeteau L. Note pour servir a l’historie des anomalies musculaires du creux de l’aisselle. Soc de Biol, Comptes Rendus Hebdomadaires des Séances et Mémoires. 1892; 44: 202-206.
- Sachatello CR. The axillopectoral muscle (Langer's axillary arch): a cause of axillary vein obstruction. Surgery. 1977; 81: 610-612.
- Saitta GF, Baum V. Langer's axillary arch. An unusual cause of axillary mass. JAMA. 1962; 180: 690.
- Takafuji T, Igarashi J, Kanbayashi T, Yokoyama T, Moriya A, Azuma S, et al. [The muscular arch of the axilla and its nerve supply in Japanese adults]. Kaibogaku Zasshi. 1991; 66: 511-523.
- Wilson JT. Further Observations on the Innervation of Axillary Muscles in Man. J Anat Physiol. 1889; 24: 52-60.
- Hollinshead WH. Anatomy for surgeons. 3rd ed. Philadelphia: Harper & Row. 1982; 1: 3.
- Turgut HB, Peker T, Gülekon N, Anil A, Karak÷se M. Axillopectoral muscle (Langer's muscle). Clin Anat. 2005; 18: 220-223.
- Ang CY, Ng SW, Tan BK. A fan-shaped axillopectoral muscle: an unusual variant of the axillary arch. Ann Plast Surg. 2009; 63: 541-542.
- Besana-Ciani I, Greenall MJ. Langer's axillary arch: anatomy, embryological features and surgical implications. The surgeon: journal of the Royal Colleges of Surgeons of Edinburgh and Ireland. 2005; 3: 325-327.
- Porzionato A, Macchi V, Stecco C, Loukas M, Tubbs RS, De Caro R, et al. Surgical anatomy of the pectoral nerves and the pectoral musculature. Clin Anat. 2012; 25: 559-575.
- Herbst KA, Miller LS. Symptomatic axillopectoral muscle in a swimmer: a case report. Am J Sports Med. 2013; 41: 1400-1403.
- Shinohara H. Does the nerve supply to both the superficial and deep surfaces of pectoralis major imply two separate developmental origins? J Anat. 1996; 188: 263-268.
- Shinohara H. A warning against revival of the classic tenets of gross anatomy related to nerve-muscle specificity. J Anat. 1996; 188: 247-248.
- Lee JH, Choi IJ, Kim DK. Axillary arch accompanying variations of the brachial plexus. J Plast Reconstr Aesthet Surg. 2009; 62: e180-181.
- Keshtgar MR, Saunders C, Ell PJ, Baum M. Langer's axillary arch in association with sentinel lymph node. Breast. 1999; 8: 152-153.
- Boontje AH. Axillary vein entrapment. Br J Surg. 1979; 66: 331-332.
- Provyn S, Balestra C, Delobel A, Wilputte F, Leduc O, Pouders C, et al. Are there hemodynamic implications related to an axillary arch? Clin Anat. 2011; 24: 964-967.
- McWhirter D, Malyon A. The axillary arch: a rare but recognised variation in axillary anatomy. J Plast Reconstr Aesthet Surg. 2008; 61: 1124-1126.
- Petrasek AJ, Semple JL, McCready DR. The surgical and oncologic significance of the axillary arch during axillary lymphadenectomy. Can J Surg. 1997; 40: 44-47.
- Spinner RJ, Carmichael SW, Spinner M. Infraclavicular ulnar nerve entrapment due to a chondroepitrochlearis muscle. J Hand Surg Br. 1991; 16: 315-317.
- Ko K, Han BK, Shin JH, Choe YH, Chung HW, Lee EH, et al. The axillopectoral muscle seen on mammography. Clin Radiol. 2006; 61: 625-629.
- Suzuma T, Sakurai T, Yoshimura G, Umemura T, Shimizu Y, Yang QF, et al. Magnetic resonance axillography for preoperative diagnosis of the axillopectoral muscle (Langer's axillary arch): a case report. Breast cancer. 2003; 10: 281-283.
- Lin C. Contracture of the chondroepitrochlearis and the axillary arch muscles. A case report. J Bone Joint Surg Am. 1988; 70: 1404-1406.