Pediatric fractures are among the most frequently encountered injuries in children and adolescents, accounting for a considerable share of emergency visits and orthopedic consultations globally [1]. Due to their increased physical activity, immature coordination, and unique anatomical characteristics, children are particularly vulnerable to trauma, especially fractures involving the upper extremities [2]. The incidence of fractures in pediatric populations shows a bimodal distribution, with peaks during early childhood and adolescence, corresponding to increased exploratory behavior and sports participation [3].

In India, where the pediatric population constitutes a significant proportion of the total demographic structure, fractures among children impose a substantial clinical and economic burden [4]. Importantly, the incidence and type of fractures are not uniformly distributed across urban and rural populations. Urban children, often exposed to sports facilities, playgrounds, concrete flooring, and vehicular traffic, face different injury mechanisms than rural children, who are more prone to fall injuries from trees, rooftops, or unguarded structures in agrarian settings [5].

Environmental and socioeconomic differences between urban and rural areas further influence injury patterns. Urban areas, while offering better access to healthcare and prompt treatment, may still see higher rates of road traffic injuries and sports-related trauma. Conversely, rural settings often lack immediate trauma care, leading to delayed presentation, reliance on traditional bone-setting methods, and underreporting of cases [6]. These discrepancies may impact both the short- and long-term outcomes of pediatric fractures.

Moreover, studies have shown that distal radius fractures, supracondylar humerus fractures, and clavicular injuries are among the most prevalent types of pediatric fractures, though their relative frequencies vary by region and age [7,8]. Males are consistently reported to have higher fracture rates than females, attributed to increased physical activity and risk-taking behavior [9]. However, limited comparative data is available on fracture epidemiology between urban and rural pediatric cohorts in the Indian context.

Identifying trends in fracture incidence and type can help develop localized preventive strategies, including safer infrastructure, targeted awareness programs, and appropriate allocation of healthcare resources [10]. Understanding the disparities in injury patterns across diverse populations also aids policymakers in framing trauma care guidelines specific to pediatric age groups.

In light of these factors, the present study aims to compare the incidence, prevalence, and types of fractures in pediatric populations from urban versus rural regions. The findings are expected to provide evidence-based insights into fracture epidemiology, guiding future healthcare planning and public health interventions.

Study Design and Setting

This was a prospective, cross-sectional, comparative study conducted over a period of 18 months (January 2023 to June 2024) at two tertiary care hospitals—one located in an urban metropolitan city and the other serving a predominantly rural population in the same state. The study received approval from the Institutional Ethics Committees of both centers, and written informed consent was obtained from the parents or guardians of all participants.

Study Population

Children aged 1 to 16 years who presented with radiologically confirmed fractures to the emergency or orthopedic outpatient departments were included. The study population was divided into two groups based on the residential address of the patients:

• Urban Group: Children residing in cities or towns with municipal governance.

• Rural Group: Children residing in villages or areas outside municipal boundaries.

Patients with pathological fractures, recurrent trauma due to metabolic bone disease, or fractures resulting from child abuse were excluded.

Sample Size Calculation

Based on previously published studies showing an average fracture prevalence of 8–10% among pediatric age groups, and aiming for a confidence interval of 95% with a power of 80%, the minimum sample size was calculated to be 200 children per group. Ultimately, 210 cases were enrolled in the urban group and 200 in the rural group.

Data Collection

Data were collected using a structured proforma that included:

• Demographic details (age, sex, socioeconomic status, place of residence)

• Mechanism of injury (fall, sports injury, road traffic accident, etc.)

• Type and site of fracture (as per radiographic diagnosis)

• Treatment provided (conservative or surgical)

• Time to presentation and hospital stay

Fractures were categorized using standard pediatric fracture classifications such as the Salter-Harris system for epiphyseal injuries, and long bone fractures were recorded by site (diaphyseal, metaphyseal, or epiphyseal).

Statistical Analysis

All data were entered into Microsoft Excel and analyzed using SPSS software version 25.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize data. Categorical variables were compared using the Chi-square test, and continuous variables were compared using the student’s t-test or Mann–Whitney U test where appropriate. A p-value < 0.05 was considered statistically significant.

A total of 410 pediatric patients were included in the study—210 from urban areas and 200 from rural areas. The findings are summarized below:

Table 1: Age and Gender Distribution

The urban group had a slight male predominance (61.4%), while the rural group showed a similar trend (59%). The most affected age group in both populations was 6–10 years, accounting for 43.8% of urban and 47.5% of rural cases. There was no statistically significant difference in gender distribution between the two groups (p = 0.64).

Table 2: Mechanism of Injury

Fall-related injuries were the most common cause in both groups, reported in 51.9% of urban and 62.5% of rural children (p = 0.03). Sports injuries were significantly more frequent in the urban group (27.1%) compared to the rural group (13.5%). In contrast, rural children had a higher proportion of falls from trees and rooftops (21.5%) versus urban children (9%).

Table 3: Type and Site of Fractures

The most common fracture in both groups was distal radius fracture, found in 26.2% of urban and 24% of rural cases. Supracondylar humerus fractures were significantly more common in rural children (22.5%) compared to urban (15.2%) (p = 0.04). Clavicle fractures and femur shaft fractures were also noted, with urban children showing higher clavicle involvement, while rural cases had more femoral injuries.

Table 4: Time to Hospital Presentation and Management

A statistically significant delay in presentation was observed in the rural group, with 42.5% arriving more than 24 hours post-injury, compared to only 15.2% in the urban group (p < 0.001). Regarding treatment, surgical intervention was required in 35% of urban and 39% of rural patients (p = 0.42), with most other cases managed conservatively via casting.

Table 1: Age and Gender Distribution of Study Population (n = 410)

Table 2: Mechanism of Injury Among Pediatric Fracture Cases

Table 3: Distribution of Fracture Types by Site

Table 4: Time to Presentation and Type of Management

The present study highlights notable differences in the epidemiology of pediatric fractures between urban and rural populations. A total of 410 children were evaluated, providing insight into how environmental context, injury mechanisms, and access to care influence fracture patterns in developing regions like India. These findings underscore the importance of region-specific preventive strategies and healthcare planning.

Age and gender distribution revealed that the majority of fractures occurred in the 6–10-year age group in both urban and rural settings. This aligns with existing epidemiological data indicating a peak incidence during early school years when children become more physically active and independent [6]. The male predominance observed in both groups is consistent with prior reports attributing higher fracture rates to increased risk-taking behavior and outdoor activity among boys [7].

Mechanisms of injury differed significantly across regions. In urban children, sports-related injuries and road traffic accidents were more frequent, reflecting the influence of organized recreational activities and increased vehicular exposure [8]. In contrast, rural children experienced more injuries from falls, particularly from trees and rooftops. This can be attributed to the agrarian lifestyle and poorly secured living environments in rural areas, which expose children to hazardous play conditions [9]. The higher rate of fall-related injuries in rural populations underscores the need for community-level awareness and structural safety interventions in homes and schools.

Fracture site analysis revealed that distal radius fractures were most common in both groups, followed by supracondylar humerus fractures and clavicle fractures. These findings are in line with global trends where upper limb fractures, especially involving the radius and humerus, are predominant in children [10]. However, supracondylar fractures were significantly more common in the rural group. This difference may be due to the increased frequency of high-impact falls in rural environments. Additionally, rural children sustained a slightly higher proportion of femur shaft fractures, possibly due to trauma from unprotected heights or contact with agricultural equipment.

One of the critical disparities observed was in the time to presentation to a healthcare facility. Urban children presented much earlier, with over 60% arriving within 12 hours of injury. In contrast, more than 40% of rural children arrived after 24 hours. This delay can be attributed to logistical challenges, transportation barriers, and reliance on traditional bone setters in rural areas [11]. Delayed presentation can lead to complications such as malunion, infection, and prolonged disability, emphasizing the need for strengthening referral systems and improving trauma awareness in rural communities.

Despite the differences in injury mechanisms and presentation times, the proportion of cases requiring surgical management was similar between groups. This indicates that the severity of fractures may not differ markedly, but timely access to care remains a major differentiating factor. Conservative management was still the most common treatment modality, which is consistent with pediatric fracture guidelines prioritizing non-invasive stabilization when appropriate [12].

Preventive strategies must be adapted to the context of each population. In urban areas, the promotion of protective gear during sports and road safety education can help reduce fracture incidence. In rural areas, improving environmental safety (e.g., installing protective barriers on rooftops, educating parents on safe play zones) and integrating community health workers to improve early referral can be effective [13].

Furthermore, public health interventions should focus on fracture surveillance systems and injury registries to monitor trends over time. Educating schoolteachers and primary caregivers in first aid and fracture identification can also help improve outcomes, particularly in rural and underserved populations [14].

The study’s strength lies in its comparative, prospective design and inclusion of both urban and rural cohorts. However, limitations include its confinement to two centers, which may not be generalizable to all regions. Socioeconomic parameters were not deeply analyzed, and seasonal variations in fracture incidence were not considered. Future studies should expand geographic coverage and explore long-term outcomes post-treatment to enhance the understanding of fracture epidemiology in children [15].

This comparative study demonstrates significant geographic differences in the incidence, type, and timing of pediatric fractures between urban and rural populations. While distal radius and supracondylar fractures were common across both groups, rural children experienced more fall-related injuries and delays in accessing care. These findings call for targeted interventions tailored to the needs of each demographic—emphasizing injury prevention, timely treatment, and community education. Strengthening healthcare access and injury surveillance in rural areas can significantly improve pediatric orthopedic outcomes and reduce the long-term burden of childhood trauma.

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