Muscular and other abnormalities in a case of Edwards' syndrome (18-trisomy)

Axillary arch muscle and pectoralis quartus: an unusual combination of two variant supernumerary muscles in the axillary region - a case report

Variant anatomy in the axillary region is of great clinical significance. It is one of the most frequently accessed regions for radical dissection surgery. During routine dissection of embalmed cadavers, we found a rare case of two accessory muscular slips emerging from the lateral border of latissimus dorsi (LD) and the inferolateral border of pectoralis major (PM), crossing the neurovascular structures in the axilla and merging distally together to the brachial fascia at the upper end of humerus below the bicipital groove. The accessory slip from LD is commonly referred to as the "axillary arch" in literature. We identified the accessory slip from the PM crossing over the axilla as pectoralis quartus. These aberrant slips can cause neurovascular compression in the axilla and can have clinical implications. Prior knowledge of the variant anatomy is the key to successful surgery in the axilla, thereby avoiding inadvertent injuries and post-operative complications.

Prevalence and anatomy of the anomalous subclavius posticus muscle and its clinical implications with emphasis in neurogenic thoracic outlet syndrome: Scoping review and meta-analysis

BACKGROUND

The subclavius muscle runs underneath the clavicle. However, there have been a few reports of a duplicated subclavius muscle which is commonly referred to as subclavius posticus muscle due to its orientation being posterior to the proper subclavius muscle. Its occurrence seems to potentially create a narrowing interval at the superior thoracic aperture as it crosses over the brachial plexus. It might also have functional influence on the shoulder girdle.

PURPOSE

To provide comprehensive gross anatomy description of the variant "subclavius posticus muscle" and to investigate its reported clinical implications with emphasis on its involvement in causing brachial plexus compression.

BASIC PROCEDURES

A scoping review with meta-analysis of the gross anatomy of the subclavius posticus muscle was conducted along with investigating its correlation to the thoracic outlet syndrome. Forty-seven articles were pooled through two rounds of the selection process. The relevant information was extracted and meta-analyzed.

MAIN FINDINGS

The scoping review and meta-analysis of the 47 articles revealed a total prevalence of 11/2069 (4.9%); 10/1369 (5.1%) in cadaveric studies, and 1/700 (5.0%) in MRI studies. The subclavius posticus muscle is a short triangular muscle with an average length of 12 cm and an average width of 1 cm. It originates from the sternal end of the first rib in most cases with reported variants of one case originating from the costoclavicular ligament and one case where it was fused with the proper subclavius muscle. Its insertion is more variable: on the superior border of the scapula with variable length in 71.35%, on the coracoid process of the scapula in 25.42%, and on the clavicle in 0.90%. The subclavian nerve seems to be the dominant nerve supply with a 57.6% prevalence, while 25.8% are innervated by the suprascapular nerve. Other reported nerves were the nerve to the myolohyoid (4.5%), accessory phrenic nerve (4.5%), and a direct branch from the brachial plexus (2.0%). The blood supply was reported (only once) to be from the suprascapular artery. However, the venous drainage was not established at all.

PRINCIPAL CONCLUSIONS

The subclavius posticus muscle is a variant muscle occurring with a reported overall prevalence of 4.9%. It can compress the brachial plexus as it runs across at the space of the superior thoracic aperture with exquisite contact, and this can lead to a neurogenic thoracic outlet syndrome. It also can be involved in the vascular thoracic outlet syndrome. Lastly, it is important not to omit its potential influence in shoulder joint instability to some extent.

Development of human limb muscles based on whole-mount immunostaining and the links between ontogeny and evolution

We provide the first detailed ontogenetic analysis of human limb muscles using whole-mount immunostaining. We compare our observations with the few earlier studies that have focused on the development of these muscles, and with data available on limb evolution, variations and pathologies. Our study confirms the transient presence of several atavistic muscles - present in our ancestors but normally absent from the adult human - during normal embryonic human development, and reveals the existence of others not previously described in human embryos. These atavistic muscles are found both as rare variations in the adult population and as anomalies in human congenital malformations, reinforcing the idea that such variations/anomalies can be related to delayed or arrested development. We further show that there is a striking difference in the developmental order of muscle appearance in the upper versus lower limbs, reinforcing the idea that the similarity between various distal upper versus lower limb muscles of tetrapod adults may be derived.

Neurogenic thoracic outlet syndrome due to subclavius posticus muscle with dynamic brachial plexus compression: a case report

Background

Neurogenic thoracic outlet syndrome is an underestimated cause of brachial weakness and pain. The subclavius posticus muscle (SPM) is an aberrant muscle originating from the medial aspect of the first rib reaching to superior border of the scapula, which may cause, depending on its activation, dynamic compression of the brachial plexus.

Case presentation

In the present study, we report about a 32-year-old male caucasian patient with weakness in radial deviation of his left hand. An isolated macrodactyly of his left middle finger had been operated twice. Electroneurography showed a carpal-tunnel-syndrome (CTS) on the left side. MRI of the brachial plexus revealed an additional muscle in the costoclavicular space, identified as SPM. To our knowledge, this is the second case report of a neurogenic thoracic outlet syndrome due to SPM, and the first case described with isolated macrodactyly and CTS in the same patient.

Conclusion

If complaints about hand weakness are only reported in cases of distinct hand positions, a dynamic compression of the brachial plexus by SPM may be the cause. A neurogenic thoracic outlet syndrome may facilitate the development of CTS.

Towards the resolution of a long-standing evolutionary question: muscle identity and attachments are mainly related to topological position and not to primordium or homeotic identity of digits

Signaling for limb bone development usually precedes that for muscle development, such that cartilage is generally present before muscle formation. It remains obscure, however, if: (i) tetrapods share a general, predictable spatial correlation between bones and muscles; and, if that is the case, if (ii) such a correlation would reflect an obligatory association between the signaling involved in skeletal and muscle morphogenesis. We address these issues here by using the results of a multidisciplinary analysis of the appendicular muscles of all major tetrapod groups integrating dissections, muscle antibody stainings, regenerative and ontogenetic analyses of fluorescently-labeled (GFP) animals, and studies of non-pentadactyl human limbs related to birth defects. Our synthesis suggests that there is a consistent, surprising anatomical pattern in both normal and abnormal phenotypes, in which the identity and attachments of distal limb muscles are mainly related to the topological position, and not to the developmental primordium (anlage) or even the homeotic identity, of the digits to which they are attached. This synthesis is therefore a starting point towards the resolution of a centuries-old question raised by authors such as Owen about the specific associations between limb bones and muscles. This question has crucial implications for evolutionary and developmental biology, and for human medicine because non-pentadactyly is the most common birth defect in human limbs. In particular, this synthesis paves the way for future developmental experimental and mechanistic studies, which are needed to clarify the processes that may be involved in the elaboration of the anatomical patterns described here, and to specifically test the hypothesis that distal limb muscle identity/attachment is mainly related to digit topology.

Reflections on the pathogenesis of Down syndrome

Present efforts to identify, isolate, and characterize in molecular terms the "consensus" segment of 21q sufficient to cause most of the major and some of the most characteristic minor manifestations of Down syndrome will soon provide answers to many questions. However, we think that a reductionist approach to explain the Down syndrome phenotype in a "linear" manner from the DNA sequence of the segment will be doomed to failure from the outset because of the open, complex, nonlinear, hierarchical nature of morphogenetic systems. Neo-Darwinism is under strong attack; most genetic changes accumulated over time may very well be of neutral effect, and detailed studies in several related groups of vertebrate species has shown that molecular and organismal evolution are largely independent of one another. It has been pointed out recently that biology lacks a theory of ontogenetic and phylogenetic development, and that a purely "genocentric" view of biology at the expense of the complexly hierarchical intrinsic epigenetic attributes of developmental systems is "out of focus with respect to ... biological organization and morphogenesis," and may be "a residue of nineteenth century romantic idealism." Down syndrome impresses us as a paradigm of increased developmental variability due to a deceleration of the rate of development (neoteny) with many anomalies of incomplete morphogenesis (vestigia), atavisms, increased morphometric variability with many decreased means, increased variances, and increased fluctuating asymmetry. These abnormalities, together with highly increased risk of prenatal death and postnatal morbidity, impaired growth, and abnormal CNS and gonadal structure and function characteristic of most aneuploidy syndromes, suggest to us that the pathogenesis of Down syndrome is best viewed in terms of the mechanisms of speciation. Transgenic experiment involving sequential or overlapping pieces of "the consensus segment" on distal 21q22.1-22.3 may help decide to what extent the Down syndrome phenotype can be resolved into the additive effect of several pleiotropic oligogenes with epistatic interaction or the indirect secondary "mass" effect of a specific segment of 21q with epistatic interaction involving multiple loci on 21q and other chromosomes.

Chromosome 18 aneuploidy: anatomical variations observed in cases of full and mosaic trisomy 18 and a case of deletion of the short arm of chromosome 18

Cases of full and mosaic trisomy 18 and a body of an infant with the 18p-syndrome were dissected in detail to compare the anatomical variations associated with these 3 chromosome imbalances involving autosome 18. The types and numbers of morphologic variations present in both the full and mosaic trisomy 18 bodies were similar to the types and numbers of variations seen in all other cases of full trisomy 18 that have been studied by gross dissection. Apart from an atrial septal defect, the body of the infant with the 18p- imbalance showed only 2 striking defects: 1) deficiencies of the levator palpebrae superioris muscle of the upper eyelid, and 2) absence of the ligament of the head of the femur. The first variation provides a morphologic basis to explain the ptosis which is observed frequently in affected individuals. Absence of the ligament of the head of the femur may be a factor contributing to congenital dislocation of the hip, which is reported occasionally in affected individuals. In addition to providing more detailed information about the phenotype of individual aneuploidy syndromes, studies of cases of different imbalances of single autosomes may provide additional insights about the genotype/phenotype relationships of specific chromosome segments.

Comparative anatomical analysis of human trisomies 13, 18, and 21: I. The forelimb

Human trisomies 13, 18, and 21 exhibit specific neuromuscular phenotypes (Pettersen and Bersu, '82) which include a high proportion of neuromuscular forelimb variations, many of which are atavistic in nature (de Beer, '58; Barash et al., '79; Aziz, '81a). In order to test the neuromuscular phenotype, examine the atavistic nature, and analyze the developmental delay of the trisomy forearm musculature, we dissected the forelimbs of five trisomy 13, ten trisomy 18, and two trisomy 21 cases. Our dissections compare favorably with the existing published trisomy cases (Opitz et al., '79; Pettersen and Bersu, '82). Additionally, we found significant differences in the stage at which developmental arrest occurred in trisomies 13 and 18 for the pectoral complex, extensor digitorum profundus, and intrinsic hand musculature. Some of these muscles, which occur normally in nonhuman primates (Cihak, '67, '69; Dunlap et al., '85), also appear briefly in normal human ontogeny (Cihak, '72), constituting further evidence for developmental delay in aneuploids. The disproportionately effected limb tissues also lend support to the evidence for some degree of autonomy in their development in normal individuals. Our observations are consistent with Shapiro's amplified developmental instability model ('83). Aneuploids may be viewed as genetic variants from which much may be learned about normal limb development, how aneuploidy affects dysmorphogenesis, and the kind of information which exists on the duplicated (or monosomic) chromosome.

Chromosomal abnormalities associated with congenital contractures (arthrogryposis)

In a study of 350 patients with multiple congenital contractures (arthrogryposis), 80 (23%) patients had mental retardation or were developmentally delayed. Out of that group of 80 patients, 13 (16%) were found to have abnormal karyotypes. Two of the thirteen had a family history of chromosomal abnormalities without congenital contractures, therefore, 11 patients had chromosomal anomalies which appeared to be associated with the congenital contractures. Five of the eleven (45%) had chromosome mosaicism, three of those had tissue mosaicism. Two had abnormal skin fibroblast cell lines and normal peripheral leukocyte chromosome studies and one had a normal bone marrow karyotype with abnormal peripheral leukocyte chromosome studies. Chromosome studies were done in these patients with congenital contractures because of developmental delay and multisystem involvement, or recognition of clinical features typical of a chromosomal syndrome. We recommend first lymphocyte; and if those are normal, then fibroblast studies be done on all patients with multiple joint contractures and developmental delay, particularly if unusual facial features or multisystem abnormalities are present.

Elaboration of the phenotypic changes of the upper limbs in the Neu-Laxova syndrome

We present two new cases and data from a detailed study of the upper limbs (structural changes, the state of peripheral nerves, arteries, muscles and bones) of three stillborn infants with the Neu-Laxova syndrome. The morphogenesis of many of the examined anatomical structures in these fetuses was anomalous. The origin of these anomalies is discussed.

Possible "atavistic" structures in human aneuploids

Comprehensive dissections of aneuploid (trisomy 18 and 13) neonates have revealed numerous supernumerary muscles that, although present in rare individuals, do not regularly occur in the human. These supernumerary muscles include: "platysma occipitalis," "rhomboideus occipitalis, "deltopectoral" complex, "latissimocondyloideus," "pectorodorsalis," "chondrohumeralis," and "peroneus digiti quinti"; a few muscles, e.g., palmaris longus and brevis are lacking altogether. One specimen exhibited a "linguofacial trunk" arising from the external carotid artery. The supernumerary muscles found in these aneuploid specimens are regularly found in monkeys and sometimes in the great apes. It is suggested that these supernumerary muscles may be "atavistic" structures. Problems in establishing homologies between these muscles among primates are discussed, and mechanisms leading to the development of these muscles in human aneuploids are proposed.

Muscular anomalies caused by delayed development in human aneuploidy

Comprehensive dissections of three infants with trisomy-13 and three with trisomy-18 have revealed several muscles which appear to be "abnormal" at the time of birth and shortly thereafter. Careful observations show that the peculiar morphology of these muscles results from delayed development rather than from anatomical malformation. The observations are compared with physiological, pathological and in vitro experimental studies of delayed embryonic development in human aneuploidy.

Anatomical defects in a case of trisomy 13 with a D/D translocation

Gross morphological defects and variations in a cytogenetically confirmed case of trisomy 13 with t (D/D) are described comprehensively for the first time. The subject, a female neonate, exhibited the following clinical features: microcephaly, sloping forehead, coloboma of the iris, bilateral cleft lip and palate, short neck, and postaxial extra digits on hands and feet. Visceral anomalies included: dextrocardia; hypertrophied right ventricle; common atrium; hypertrophied sinus venosus; persistent left superior vena cava; a large, patent ductus arteriosus interventricular septal defect; Meckel diverticulum; common mesentary; omphalocele; accessory renal arteries and veins; bicornuate uterus; bilateral agenesis of the olfactory bulb; partial holoprosencephaly; and the ulnar nerve passed anterior to the medial epicondyle, bilaterally. Supernumerary muscles included: pectorodorsalis ("achselbogen"); chondroepitrochlearis; sternochondroscapularis; accessory heads of biceps brachii; and radiocarpus. The following muscles were absent: stylohyoideus; pectoralis minor (left); subclavius; palmaris longus and brevis; plantaris; and peroneus tertius. The following muscles exhibited unusual variations: digastricus; mylohyoideus; pectoralis major; and extensor indicis. These findings are compared and contrasted with those recently reported in primary trisomy 13 and 18 and with a case of trisomy 13 with a D/G translocation.