What are the criteria for referring a patient with orthopedic (ortho) conditions to an inpatient facility?

Orthopedic Inpatient Referral Criteria

Refer patients to orthopedic inpatient services when they have conditions requiring surgical intervention, complex fractures, bone/joint infections, or severe complications that cannot be managed in an outpatient setting.

Pediatric Orthopedic Inpatient Referral Criteria

Congenital and Developmental Conditions Requiring Admission

• Infants with limb malformations (clubfoot, congenital limb deficiency) that require surgical correction 1
• Developmental dysplasia of the hip in infants, children, and adolescents when closed or open reduction is indicated 1
• Significant spinal deformity (scoliosis or kyphosis) requiring surgical stabilization 1
• Significant limb deformity secondary to metabolic bone disease, growth arrest, or limb length discrepancy requiring operative correction 1

Acute Infectious Conditions

• Bone or joint infections (osteomyelitis, septic arthritis) requiring surgical drainage, debridement, and intravenous antibiotics 1
• These patients need ongoing inpatient management with PICC line placement at time of surgery 1
• Consider at-home intravenous antibiotic treatment after initial surgical management to minimize hospital stay 1

Hip Pathology Requiring Admission

• Perthes disease (osteochondritis of the femoral head) when surgical intervention is indicated 1
• Slipped capital femoral epiphysis in children and adolescents, which typically requires urgent surgical pinning 1

Trauma Requiring Inpatient Management

• Multiple skeletal trauma or complex fractures and dislocations 1
• Open fractures requiring washout and windowed cast application 1
• Dislocations that cannot be reduced in the emergency department and require operative reduction 1
• Fractures with neurovascular compromise, compartment syndrome, or other severe complications 1

Neuromuscular Conditions

• Disability, deformity, or gait abnormality secondary to cerebral palsy, spina bifida, muscular dystrophy, or spinal muscular atrophy when surgical intervention is planned 1

Sports Injuries Requiring Surgery

• Anterior cruciate ligament tears, meniscal tears, cartilage injuries requiring arthroscopic or open repair 1
• Ankle or shoulder instability requiring surgical stabilization 1

Adult Orthopedic Inpatient Referral Criteria

Severe Complications and Rehabilitation Needs

• Severe complications requiring skilled nursing and professional support 1
• Seriously disabled patients requiring intensive rehabilitation in an inpatient setting 1
• Patients requiring close observation and continuous surveillance due to high risk for adverse events from their conditions and treatments 2

Emergency and Urgent Conditions

• Emergencies or urgencies requiring rapid hospital assessment and immediate intervention 1
• Conditions with immediate, permanent morbidity or lack of practical remedial options 1

Surgical Candidates

• Patients with joint symptoms substantially affecting quality of life that are refractory to non-surgical treatment and require total joint arthroplasty 3, 4
• Before surgical referral, ensure patients have completed core treatments: weight loss (if BMI ≥25), structured exercise programs, physical therapy, acetaminophen, and topical NSAIDs 3, 4
• Refer before prolonged and established functional limitation develops, as delayed referral worsens outcomes 3, 4

Key Documentation for Referral

When referring to orthopedic inpatient services, include:

• Failed conservative treatments with specific agents, doses, duration, and response 4
• Functional limitations and how substantially they affect quality of life 4
• Mechanical symptoms (true locking, instability) that may indicate need for surgical intervention 4, 5
• Comorbidities (cardiovascular, renal, gastrointestinal conditions, smoking status, BMI) that may affect surgical candidacy 4
• Pain severity and pattern, including intensity, duration, timing, and impact on daily activities 4

Common Pitfalls to Avoid

• Do not delay referral for bone/joint infections, as these require urgent surgical drainage and prolonged antibiotic therapy 1
• Do not refer for arthroscopic procedures for non-mechanical symptoms or radiographic findings alone 3
• Do not use patient age, sex, smoking, or obesity as barriers to referral for appropriate surgical intervention 3
• Ensure adequate pre-referral conservative management has been documented before elective surgical referrals 3, 4