Early Referral in Brachial Plexus Injury: An Ethical Obligation

Traumatic brachial plexus injuries (TBPIs) are debilitating and life-altering.^1,2 Delayed referral to a brachial plexus surgeon (BPS) impacts reconstructive options and limits recovery, potentially compromising a patient’s lifelong functional status.³ Providers involved in the initial evaluation of patients with TBPIs have an ethical obligation to promptly refer them to a BPS. Similarly, BPSs have an ethical obligation to educate their peers and advocate for timely referrals.

Timing of TBPI reconstruction is partially dependent on the mechanism of nerve injury (Table 1). Sharp, open injuries and high-velocity gunshot wounds require immediate referral to a BPS for surgical exploration and possible primary repair.^2,4 Immediate referrals are also indicated in blunt, open injuries; so injured nerves can be tagged and repaired in 3–4 weeks, allowing for demarcation of injured tissue. Exact timing of repair after closed injury remains controversial but is, nevertheless, time sensitive. The regenerative capacity of severed proximal nerve stumps and the capacity of distal nerve stumps to support regenerating axons decrease with time.³ Even if the neuromuscular connection is re-established, irreversible changes limit recovery.² Ideal timing for nerve reconstruction in this setting is within 6 months of injury, although earlier operative times may result in improved outcomes.^2,3 Beyond 12 months, remaining surgical options are limited. Unfortunately, current data suggest the referral pattern can be far outside this timeframe.³

Table 1.

Treatment Options by Mechanism of Injury

Injury		Timing of Referral	Treatment Options
Open
	Sharp	Immediate	Early exploration and reconstruction
	High velocity	Immediate	Early exploration and reconstruction
	Blunt	Immediate	Early exploration and delayed reconstruction
Closed		Controversial	<6 months: nerve reconstruction >6 months: free-muscle transfer, shoulder arthrodesis, amputation

In a study by Zhang et al,¹ 44% of patients experienced delayed referral (defined as more than 3 months after injury), with 17 months being the greatest recorded delay. The three most common reasons for delayed referral were delay by referring providers, misdirected referral (eg, to a shoulder surgeon), and polytrauma. Commonly associated factors were the initial treating hospital, Medicare insurance, and motorcycle accident as the mechanism of injury (ie, the most common cause of TBPIs). Although many confounding variables may exist, first-line providers have a clinical and ethical obligation to ensure proper referrals are completed.

To facilitate timely referral, BPSs must understand the established referral networks within their communities. If nonexistent or incomplete, they must participate in formalizing these networks, similar to the collaboration between the American Society for Surgery of the Hand and the American College of Surgeons for finger replantation.⁵ Another important part of successful brachial plexus management is direct communication between the BPS and index provider, which minimizes error and maximizes efficiency in the transfer of information.

We propose that referral to a BPS within 72 hours of initial evaluation is mandatory in delivering ethical care. Once consulted, BPSs are obligated to conduct an evaluation within 3 weeks (or sooner, if indicated). To combat delayed referral, we advocate for improved educational outreach to the most common referring providers (eg, emergency medicine, trauma surgery) and the establishment of regional referral centers of excellence (Table 2).

Table 2.

Actionable Items for Index Providers to Combat Delayed Referral

Combatting Delayed Referral
Referral within 72 hours
Establishing regional referral pathways
Educational outreach to common referring providers

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.