Orthopedic Inpatient Referral Criteria

Pediatric Orthopedic Conditions

• Infants with limb malformations, such as clubfoot or congenital limb deficiency, require surgical correction, according to the American Academy of Pediatrics 1
• Developmental dysplasia of the hip in infants, children, and adolescents requires closed or open reduction, as indicated by the American Academy of Pediatrics 1
• Significant spinal deformity, such as scoliosis or kyphosis, requires surgical stabilization, as recommended by the American Academy of Pediatrics 1
• Bone or joint infections, such as osteomyelitis or septic arthritis, require surgical drainage, debridement, and intravenous antibiotics, according to the American Academy of Orthopaedic Surgeons 1, 2
• Patients with bone or joint infections may require ongoing inpatient management with PICC line placement at the time of surgery, as suggested by the American Academy of Orthopaedic Surgeons 2
• Consider at-home intravenous antibiotic treatment after initial surgical management to minimize hospital stay, as recommended by the American Academy of Orthopaedic Surgeons 2
• Multiple skeletal trauma or complex fractures and dislocations require inpatient management, according to the American Academy of Pediatrics 1
• Open fractures require washout and windowed cast application, as indicated by the American Academy of Orthopaedic Surgeons 2
• Dislocations that cannot be reduced in the emergency department require operative reduction, as recommended by the American Academy of Orthopaedic Surgeons 2
• Fractures with neurovascular compromise, compartment syndrome, or other severe complications require inpatient management, according to the American Academy of Pediatrics 1

Adult Orthopedic Conditions

• Severe complications, such as those requiring skilled nursing and professional support, may necessitate inpatient referral, as suggested by the European League Against Rheumatism 3, 4
• Seriously disabled patients may require intensive rehabilitation in an inpatient setting, according to the European League Against Rheumatism 3, 4
• Emergencies or urgencies, such as conditions requiring rapid hospital assessment and immediate intervention, may require inpatient referral, as recommended by the European League Against Rheumatism 3, 4
• Conditions with immediate, permanent morbidity or lack of practical remedial options may require inpatient referral, as indicated by the American Academy of Orthopaedic Surgeons 2
• Patients with joint symptoms substantially affecting quality of life that are refractory to non-surgical treatment may require total joint arthroplasty, as recommended by the American College of Rheumatology 5, 6
• Before surgical referral, ensure patients have completed core treatments, such as weight loss, structured exercise programs, physical therapy, acetaminophen, and topical NSAIDs, as suggested by the American College of Rheumatology 5, 6
• Refer patients before prolonged and established functional limitation develops, as delayed referral worsens outcomes, according to the American College of Rheumatology 5, 6

Referral Documentation

• Include failed conservative treatments with specific agents, doses, duration, and response in referral documentation, as recommended by the American College of Rheumatology 6
• Document functional limitations and how substantially they affect quality of life, as suggested by the American College of Rheumatology 6
• Include mechanical symptoms, such as true locking or instability, that may indicate the need for surgical intervention, as recommended by the American College of Rheumatology 6, 7
• Document comorbidities, such as cardiovascular, renal, or gastrointestinal conditions, that may affect surgical candidacy, as suggested by the American College of Rheumatology 6
• Include pain severity and pattern, including intensity, duration, timing, and impact on daily activities, in referral documentation, as recommended by the American College of Rheumatology 6

Pitfalls to Avoid

• Do not delay referral for bone or joint infections, as these require urgent surgical drainage and prolonged antibiotic therapy, according to the American Academy of Pediatrics and the American Academy of Orthopaedic Surgeons 1, 2
• Do not refer patients for arthroscopic procedures for non-mechanical symptoms or radiographic findings alone, as recommended by the American College of Rheumatology 5
• Do not use patient age, sex, smoking, or obesity as barriers to referral for appropriate surgical intervention, according to the American College of Rheumatology 5
• Ensure adequate pre-referral conservative management has been documented before elective surgical referrals, as suggested by the American College of Rheumatology 5, 6