The epidemiology of fractures in children
Louise Renniea, Charles M. Court-Brownb,*, Jacqueline Y.Q. Moka,
Thomas F. Beattiea
aRoyal Hospital for Sick Children, Sciennes Road, Edinburgh EH9 1LF, United Kingdom
bRoyal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh EH16 4SU, United Kingdom
Accepted 29 January 2007
Injuries are common in childhood with studies show-
each year.12,11It has been shown that fractures
account for 10—25% of childhood injuries5and that
the effects of paediatric fractures are considerable
with significant restriction of activity.3Despite this
the epidemiology of paediatric fractures is poorly
understood. Landin4documented the epidemiology
of fractures in children in Malmo ¨ in Sweden and
showed that the incidence of fractures almost
there have been comparatively few studies since
then and there has been recent debate12,5,7,6about
the incidence of fractures in children. We analysed
all paediatric fractures presenting to hospital in
Edinburgh, Scotland in 2000 to ascertain their inci-
dence, demonstrate which fractures were most
common and investigate the causes of fracture in
different age groups. We also set out to examine the
Injury, Int. J. Care Injured (2007) 38, 913—922
Edinburgh, Scotland in 2000 was undertaken. It showed that the incidence of
Analysis of paediatric fractures shows that there are six basic fracture distribution
curves with six fractures showing a bimodal distribution but most having a unimodal
with age with falls from below bed height (<1 m) being the commonest cause of
Themajority of fracturesinchildreninvolvetheupperlimb.Lowerlimb fractures
are mainly caused by twisting injuries and road traffic accidents. The incidence of
fractures in cyclists and pedestrians remains relatively high whereas the incidence
in vehicle occupants is low suggesting that road safety programs have been
successful. Similar programs should be instituted for young cyclists. The importance
of accident prevention programmes in the home is also highlighted.
# 2007 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: +44 1312423516.
E-mail address: email@example.com (C.M. Court-Brown).
0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved.
fracture distribution curves of all fractures to see if
there was a reproducible set of curves, which would
encompass all fractures.
Materials and methods
A retrospective analysis of all paediatric fractures in
the council areas of the city of Edinburgh, Mid-
lothian and East Lothian in Scotland was underta-
ken. All in-patient and out-patient fractures in
children aged less than 16 years of age were exam-
ined. These patients are all treatedin two hospitals,
the Royal Hospital for Sick Children in Edinburgh and
the Royal Infirmary of Edinburgh. There are no other
paediatric trauma units in the area.
Both hospitals keep prospective databases of all
in-patient and out-patient fractures. All the rele-
vant databases in the year 2000 were analysed to
provide epidemiological information about the frac-
tures presenting in this year. In all cases X-rays were
reviewed to exclude incorrect diagnoses and soft
tissue injuries. All the X-rays were reviewed by one
author (LR) to avoid inter-observer error. Where
there was debate about the presence of a fracture
an opinion was obtained from an experienced pae-
diatric radiologist. Parameters that were recorded
from the databases and X-rays included age, gender,
date of injury, mechanism of injury, site of fracture
and involvement of a physis.
The site of fracture was recorded using standard
anatomical sites. All fractures were listed individu-
ally with multiple fractures recorded separately.
However, multiple fractures of the finger and toe
phalanges, metacarpals, metatarsals and vertebrae
were recorded as one fracture. In 2000, the practice
and skull fractures would be missed. For these
reasons, skull and rib fractures were excluded from
Seven basic mechanisms of injury were recorded.
These were twisting injuries, falls from below bed
height (<1 m), falls down stairs or slopes, falls from
above bed height, blunt trauma, sports injuries and
road traffic accidents. Fractures occurring as a
result of road traffic accidents were subdivided into
those occurring in cyclists, motorcyclists, pedes-
trians and vehicle occupants. Stress, insufficiency
and pathological fractures were combined together
but there were insufficient numbers to permit
The population was divided into four age ranges.
These were infants (0—1 years), pre-school children
(2—4 years), school children (5—11 years) and ado-
lescents (12—16 years). All patients from outwith
Edinburgh, East Lothian and Midlothian were
excluded from analysis but patients from the area
who had their initial treatment elsewhere were
included. Fracture incidence was calculated from
the relevant figures from the 2001 census. Data was
manipulated in Excel spread sheets and statistical
analysis was performed using SPSS.
The population of patients in Edinburgh, Midlothian
and East Lothian aged less than 16 years at the 2001
census was 108,987 with a gender ratio of 51:49%
males to females. During the year 2000 there were
2198 fractures in 2168 patients. Twenty-seven
patients (1.2%) presented with more than one frac-
ture,24 patientssustained 2 fractures and3 patients
had 4 fractures. The overall incidence was 20.2
fractures/1000/year and the overall average age
was 9.7 years. Analysis of gender showed that
61.4% of patients were males with an average age
1000/year. 38.6% were females with an average age
of 8.9 years (median 9.5) and an incidence of 15.7/
fractures were open and 14.8% were physeal.
914 L. Rennie et al.
Overall fracture incidence curves. (^) Boys and (&) Girls.
tibia, patella, pelvis, talus, calcaneus, midfoot,
proximal femur and spine are very rare in childhood
and distribution curves cannot be constructed with-
out a much larger study. However, we have shown
that these fractures are commoner in older boys and
distribution and are uncommon in younger children.
We believe that this is important when considering
the spectrum of fractures caused by non-accidental
injuries. Unusual fractures such as those mentioned
above and the humeral diaphyseal fracture which
occur in older children after high-energy injuries
children until proven otherwise.
1. Court-Brown CM, Koval KJ.The epidemiology of fractures In:
Bucholz RW, Heckman JD, Court-Brown CM, editors. Rock-
wood and Green’s Fractures in adults. 6th ed., Philadelphia:
Lippincott, Williams and Wilkins; 2006. p. 95—144.
2. Hassan I, Dorani BJ. Sports related fractures in children in
north east England. Emerg Med J 2001;18:167—71.
3. Kopjar B, Wickizer TM. Fractures among children: incidence
and impact on daily living. Inj Prev 1998;4:194—7.
4. Landin LA. Fracture patterns in children. Analysis of 8,682
fractures with special reference to incidence, etiology and
secular changes in a Swedish urban population 1950—1979.
Acta Orthop Scand 1983;54(Suppl.):202.
5. Landin LA. Epidemiology of children’s fractures. J Paediatr
Orthop B 1997;6:79—83.
6. Lyons RA, Delahunty AM, Kraus D, et al. Children’s fractures:
a population based study. Inj Prev 1999;5:129—32.
7. Lyons RA, Sellstrom E, Delahunty AM, et al. Incidence and
cause of fractures in European districts. Arch Dis Child
years of accidental injuries. Public Health Rep 1966;81:
9. Moustaki M, Lariou M, Petridou E. Cross country variation of
fractures in the childhood population. Is the origin biological
or ‘‘accidental’’. Inj Prev 2001;7:77.
10. Ramsay LJ, Moreton G, Gorman DR, et al. Unintentional
home injury in preschool-aged children: looking for the
key-an exploration of the inter-relationship and relative
11. Scheidt PC, Harel Y, Trumble AC, et al. The epidemiology of
nonfatal injuries among US children and youth. Am J Public
12. Walsh SSM, Jarvis SN, Towner EM, Aynsley-Green A. Annual
incidence of unintentional injury among 54000 children. Inj
13. Worlock P, Stower M, Barbor P. Patterns of fractures in
accidental and non-accidental injury in children: a compara-
tive study. BMJ 1986;293:100—2.
risk factors.Public Health
922 L. Rennie et al.