Reliability-Oriented Multilingual Orthopedic Diagnosis: A Domain-Adaptive Modeling and a Conceptual Validation Framework

Large Language Models (LLMs) are increasingly proposed for clinical decision support including multilingual diagnosis in low-resource settings. However, their reliability, calibration and safety characteristics remain insufficiently understood for structured, high-risk tasks. We present a system-level analysis of multilingual orthopedic diagnosis from free-text clinical notes in English, Hindi and Punjabi. We evaluate three modeling regimes: (i) task-aligned multilingual transformer encoders, (ii) a task-fine-tuned baseline (DistilBERT), and (iii) a domain-adaptive architecture tailored to orthopedic text (IndicBERT-HPA). These models are compared with zero-shot, instruction-tuned LLMs to assess suitability for structured diagnostic classification. Results indicate that while LLMs exhibit strong linguistic fluency, they show unstable calibration and reduced reliability under structured multilingual conditions, particularly in low-resource languages. These findings are specific to zero-shot evaluation and do not imply limitations of fine-tuned models. Domain-adaptive specialization substantially improves cross-lingual discrimination and confidence behavior. IndicBERT-HPA, with language-specific orthopedic adapter heads achieves consistently strong performance across six diagnostic categories and more predictable deployment characteristics than task-only adaptation. Building on these observations, we outline a conceptual deterministic agent-based validation framework for future implementation, formalizing evidence checks, language-sensitive validation and conservative human-in-the-loop gating. Reliable multilingual clinical decision support requires specialized architecture, explicit reliability analysis, and structured validation for safety-critical systems.