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Ann Anat 189 (2007) 290—294

www.elsevier.de/aanat

Bilateral arterial and nervous variations in the

human upper limb: A case report
Daniela Salopek1, Ana Dujmovic,1, Julijana Hadjina, Iva Topic

Department of Anatomy, Zagreb University School of Medicine, Salata 11, HR-10000 Zagreb, Croatia

Received 18 July 2006; accepted 7 September 2006

KEYWORDS Summary
Anatomical
During routine dissection, we found bilateral arterial and nervous anomalies in a
variations;
female cadaver. On the left side the axillary artery divided into a medial brachial
Axillary artery;
artery and lateral profunda brachii artery, and the musculocutaneous nerve arose
Brachial artery;
from the upper trunk of the brachial plexus, before the formation of the lateral
Musculocutaneous
cord. On the right side a common trunk that divided into the circumflex scapular
nerve
artery, thoracodorsal artery and posterior circumflex humeral artery was observed,
while the musculocutaneous nerve fused with the median nerve.
& 2006 Elsevier GmbH. All rights reserved.

Introduction the axillary artery have been described, its high

Variations of the main arteries of the upper limb,
in their origin, branching and course, have been the
subject of many anatomical studies because of
their relatively high incidence (Watanabe et al.,
1985), and clinical and surgical importance (Jurjus
et al., 1999; Pandey et al., 2004). The most
frequent anatomical variations of the axillary
artery are the persistant superficial brachial artery,
high division of the brachial artery, and high
division of the radial and ulnar arteries (McCormack
et al., 1953; Jurjus et al., 1986; Uglietta and Kadir,
1989; Gonzalez-Compta, 1991). Rare variations of
division into two major stems named according to
their localization as deep brachial artery and
superficial brachial artery (Cavdar et al., 2000).
The division of axillary artery into superficial and
deep stems was found to be more frequent in
afroamericans (13.4%) than in caucasions (4.6%)
(De Garis and Swartley, 1928). Complete absence of
the brachial artery has also been reported (Ciervo
et al., 2001).
We describe a case of bilateral axillary artery
variations combined with abnormal pattern of the
musculocutaneous nerve.

Corresponding author. Tel.: +385 14590224; Materials and methods

fax: +385 14590195.
E-mail address: adujmov@mef.hr (A. Dujmovic). The anomalies of the axillary artery and muscu-
1
These two authors equally contributed to this report. locutaneous nerve were found in the upper

0940-9602/$ - see front matter & 2006 Elsevier GmbH. All rights reserved.
doi:10.1016/j.aanat.2006.09.007
 ARTICLE IN PRESS
Bilateral arterial and nervous variations 291

extremities of a 60-year-old caucasian female
cadaver during routine educational dissection at
the Department of Anatomy of the Zagreb Uni-
versity School of Medicine in the 2005/2006
academic year. The findings were photographed
and documented on diagrams. The length of the
vessels and nerves was measured using a meter.
Results
Right arm variations
On the right side the first two parts of the axillary
artery and its branches were normal, but the third
part, begining below the pectoralis minor muscle,
gave rise to a common trunk, 0.5 cm long, that
divided into the circumflex scapular artery, thor-
acodorsal artery and posterior circumflex humeral
artery. There was no subscapular artery (Fig. 1).
Circumflex scapular artery curved around the
axillary border of the scapula and entered the
infraspinous fossa. The thoracodorsal artery con-
tinued down the latissimus dorsi. The posterior
circumflex humeral artery runs backward with the
axillary nerve through the quadrangular space. The
anterior circumflex humeral artery originated from
the axillary artery, as it generally does, ran
horizontally, beneath the coracobrachialis muscle
and short head of the biceps brachii, in front of the
neck of the humerus, gave off a branch which
supplies the head of the humerus and the shoulder
joint, and continued beneath the long head of the
biceps brachii and deltoideus to anastomose with
the posterior circumflex humeral artery. The
musculocutaneous nerve arouse from the lateral
cord of the brachial plexus. Two centimeters below
the coupling of lateral and medial root of the
median nerve, the musculocutaneous nerve fused
with the median nerve (Fig. 1). After 2 cm of their
joined course, musculocutaneous nerve ran sepa-
rately again, giving off branches to the coracho-
brachialis, biceps brachii and brachialis and
continuing into the forearm as the lateral ante-
brachial cutaneous nerve.
Left arm variations
On the left side, just below the clavicle, the
axillary artery divided into two main arteries of the
same diameter: the medial brachial artery and
lateral profunda brachii artery (Fig. 2). At the
begining of its course, the profunda brachii artery
lay between the musculocutaneous nerve and the
lateral root of the median nerve. In the axillary
fossa, it gave off the anterior and posterior
circumflex humeral artery and subscapular artery,
all of the same size. The anterior circumflex
humeral artery coursed toward the neck of the

Figure 1. Right arm variations. The third part of the axillary artery gave rise to a common trunk, the origin of the
circumflex scapular artery, thoracodorsal artery, and posterior circumflex humeral artery. The musculocutaneous nerve
fused with the median nerve in length of 2 cm. Abbreviations: BA – brachial artery, CT – common trunk, CSA – circumflex
scapular artery, MCN – musculocutaneous nerve, MN – median nerve, PCHA – posterior circumflex humeral artery, TDA –
thoracodorsal artery.
 ARTICLE IN PRESS
292 D. Salopek et al.

Figure 2. Left arm variations. The axillary artery divided into two main arteries: medial brachial artery and lateral
profunda brachii artery. The musculocutaneous nerve arose from the upper trunk of the brachial plexus, before the
formation of the lateral cord and fused with the median nerve for a length of 2 cm. Abbreviations: AA – axillary artery,
BA – brachial artery, MCN – musculocutaneous nerve, MN – median nerve, PBA – profunda brachii artery, PCHA –
posterior circumflex humeral artery, RN – radial nerve.

humerus. The posterior circumflex humeral artery Discussion

accompanied the axillary nerve through the quad-
rangular foramen. The subscapular artery coursed
toward the thoracic wall. After branching, the
profunda brachii artery followed the radial nerve
into the groove on the posterior surface of the
humerus, where it lay between the medial and
lateral head of the triceps brachii. During its course
it gave off three small muscular branches. On the
lateral side of the arm it pierced the lateral
intermuscular septum of the arm, descended and
ended by giving a small anastomosing branch for
the radial artery.
The brachial artery ran along the median nerve
down the upper arm, without giving off any
branches. After reaching the cubital fossa, it
divided into the radial and ulnar artery, the usual
branches. The course of the latter arteries on the
forearm was normal.
The musculocutaneous nerve arouse from the
upper trunk of the brachial plexus, before the
formation of the lateral cord (Fig. 2). It ran down in
front of the cord roots, encircled the brachial
artery together with the lateral root of the median
nerve and then, 1 cm below, fused with the median
nerve. After 2 cm of their common course, the
musculocutaneous nerve ran separately again,
giving off muscular branches and continuing as
the lateral antebrachial cutaneous nerve.
The axillary artery, the continuation of the
subclavian artery, commences at the outer border
of the first rib, and ends at the lower border of
the teres major tendon (Standring, 2004). To
facilitate the description it is anatomically divided
into three parts according to the pectoralis minor
(Cavdar et al., 2000). The first part lies proximal,
the second deep, and the third distal to the muscle
(Ellis, 1978; Hollinshead, 1976; Moore, 1992;
Venieratos and Anagnostopoulou, 1998). The
branches of the axillary are: from the first part –
superior thoracic artery, from the second part –
thoraco-acromial and lateral thoracic artery, and
from the third part – subscapular, posterior
circumflex humeral and anterior circumflex hum-
eral artery. At the lower border of the teres major,
the axillary artery becomes the brachial artery
(Standring, 2004). It goes along the humerus down
to the elbow, and gives rise to the profunda brachii
artery, that curves around the back of the humerus
to supply the blood to the triceps brachii, and
to shorter anterior muscular and descending
branches.
Variations in the origin of the main arteries of the
upper limb have been documented before (Bergman
et al., 1985; McCormack et al., 1953; Rodriguez-
Niedenfuhr et al., 2001). These variations can
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Bilateral arterial and nervous variations
be explained by disturbed embryologic develop-
ment of the vascular plexus of the limb buds (Jurjus
et al., 1999). The prevalence of various upper
extremity anomalies range from 9% to 18.5% (Ciervo
et al., 2001). The origin of the profunda brachii
artery is very variable. It may rise from the third
part of the axillary artery or together with one or
more branches of that vessel (De Garis and
Swartley, 1928; Charles et al., 1931), or arise as a
common trunk with the superior ulnar collateral,
anterior and posterior circumflex humeral artery
(Bergman et al., 1985). In the described case, the
left profunda brachii artery originated from the
third part of the axillary artery, just below the
inferior border of the scapulae, and continued down
the lateral side of the upper limb following the
radial nerve. The brachial artery was the continua-
tion of the axillary artery, as in most cases
(Standring, 2004).
A large common trunk on the right side has been
described before as a first vessel originating from
the axillary artery and giving rise to subscapular
branches, profunda brachii artery, posterior cir-
cumflex humeral artery, circumflex scapular artery,
and thoracodorsal artery (Claassen et al., 2006). A
small trunk dividing into posterior circumflex
humeral artery and subscapular artery was found
on the left side of the same individual (Claassen et
al., 2006). Among mammals, the branches of the
axillary artery and brachial artery are often
described as taking off from a common trunk and
the formation of such a trunk in humans can be
interpreted as repetition of the mammalian plesio-
morphic condition of the arteries (Claassen et al.,
2006). In our case we describe a common trunk on
the right side, giving rise to the circumflex scapular
artery, thoracodorsal artery and posterior circum-
flex humeral artery.
Numerous communications between the median
and musculocutaneous nerve have been classified
(Choi et al., 2002; Kosugi et al., 1986; Venieratos
and Anagnostopoulou, 1998). Some authors de-
scribe the fusion of the two nerves (Watanabe et
al., 1985). Embyrological studies have revealed
that this fusion could be explained as failed
differentiation of the brachial plexus (Shinohara
et al., 1990). This failure can be associated with
local muscle variations (Kosugi et al., 1992). In our
case we report bilateral partial fusion, 2 cm long,
between the median and musculocutaneous nerves,
without any muscle variations. The musculocuta-
neous nerve is known to be double, short, or
absent. It can arise from the lateral cord (90.5%),
from the lateral and posterior cords (4%), from the
median nerve (2%), from the medial and lateral
cords (1.4%) or from the posterior cord (1.4%)
293
(Tountas and Bergman, 1993). We describe a case of
a very long musculocutaneos nerve with a high
origin – on the left side the nerve arised from the
upper trunk of the brachial plexus, before the
formation of the cords.
Arterial and neural variations of the upper limb
have highly practical importance for surgeons,
radiologists, neurologists (Morris et al., 2005;
Bianchi, 2001; Pettersson et al., 1985). Increasing
use of invasive diagnostic and interventional
procedures requires proper knowledge of human
anatomy, both normal and abnormal, in order to
avoid complications and provide adequate care.
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