Child injury is one of the most immediate public health threats, resulting in the deaths of nearly 2,000 children under the age of 14 every day around the world (1). Fractures are extremely common in the pediatric age group. Of all these injuries, fractures account for 10%–25% (2–4). The annual incidence rates of fractures have dramatically increased in children under 16 years, rising from 3.6 per 1,000–50 per 1,000. There was a doubled risk of fracture in boys aged 13–15 compared with their female peers. Typically, the incidence peaks at ages 11–12 for girls and 13–14 for boys. The lifetime risk of sustaining a fracture during childhood is approximately 42%–64% for boys and 27%–40% for girls; however, these gender distributions may vary between bone sites (5, 6). In children, the most common sites of injury are the upper limb, elbow, and forearm (7).

Activities associated with fractures were primarily soccer and bicycling. However, when comparing the total number of injuries associated with each activity, we found a doubled risk of fractures during rollerblading/skating or snowboarding (60%) compared to playing soccer (38%) or bicycling (33%) (8). Scaphoid fractures, which are infrequent in children, accounted for 9% of all fractures resulting from rollerblading/skating (9, 10). Injuries occur in various locations during different activities, and their patterns change over time. For instance, sports participation is encouraged to increase physical activity among children in most developed countries (11, 12). In contrast, other daily activities, such as walking, tend to decrease (13, 14).

A substantial proportion of pediatric fractures are preventable. In high-income countries (HICs), there has been a general decline in injuries over the past 15 years. However, children from low- and middle-income countries (LMICs) are disproportionately affected, accounting for over 90% of unintentional injury-related deaths globally (15, 16). In LMICs, efforts have largely focused on addressing mortality from communicable illnesses, resulting in a widening gap in injury mortality (17). The burden of pediatric fractures is significant, but many can be prevented through simple and cost-effective community-level interventions aimed at children and their families (1). The Ethiopian health sector program prioritizes the prevention of injuries and violence. To address pediatric trauma, the Ministry of Health (MoH) has been implementing Emergency Triage Assessment and Treatment Plus (ETAT+) strategies (18).

Without understanding the causes of injuries, as well as the conditions and environments in which they arise at different developmental stages, it is impossible to identify risky behaviours that can be addressed with age-appropriate preventive strategies (19). To the best of our knowledge, few studies have been conducted in Ethiopia regarding the incidence and patterns of pediatric fractures. Without comprehensive data on pediatric fractures, it is challenging to set priorities, formulate policies, and implement preventive measures. Therefore, this study aimed to determine the incidence and patterns of pediatric fractures at selected hospitals in Addis Ababa.

A multi-center cross-sectional study was conducted from October 10, 2023, to February 15, 2024, in the emergency unit and pediatrics ward of three public hospitals in Addis Ababa, Ethiopia: Tikur Anbesa Specialized Hospital (TASH), Yekatit 12 Hospital, and Alert Hospital. All three hospitals serve as teaching facilities and referral centers at both the city administration and federal levels. TASH is the largest tertiary hospital in the country and functions as one of the orthopedic centers, managing approximately 1,000 pediatric fracture cases per year. Yekatit 12 Hospital (Y12H) attends to around 250 pediatric fracture cases in its emergency and pediatric surgical wards annually. Alert Hospital (AH) sees about 4,600 pediatric emergency admissions annually, with 8% of these being pediatric fractures.

All children under 15 years old who sustained trauma and were admitted to TASH, Y12H, and AH were considered as the source population. The study population included all children under 15 years old who visited and were admitted to the selected hospitals during the study period, provided their caregivers gave voluntary consent for participation, and met the inclusion criteria. Children who died on arrival, those without an attendant, and those who declined consent were excluded from the study.

The current study found that, from 648 pediatric trauma children, the incidence of fractures was approximately 28% (95% CI: 26.5–29.7). Males have a higher incidence of fractures (72%) compared to females (28%), in relation to falls, RTA, and assaults, which account for 79%, 15.4%, and 5.6% of cases, respectively. This finding is consistent with studies conducted in Kenya (19), Italy (20), and the United States (22). However, our results differ from a study conducted at the Children's Hospital of Michigan, where females accounted for a greater proportion in the 10–12 year age group (23). This disparity in injury incidence may be attributed to age-related behavioral changes, such as males engaging in more physically risky activities.

The findings of the study indicate that children aged 6–10 years living in urban areas have a higher incidence of fractures. The mode of injury from RTA (p = 0.014), the place of fall (p < 0.001), two-structure injuries (p = 0.034), and the number of fractures (p = 0.012) were statistically significant in relation to the age of the children. These results are consistent with other studies conducted in South Wales (5) and Britain (6). The higher frequency of fractures may be attributed to increased participation in both organized and unstructured sports, as well as generally high levels of physical activity during this age.

Regarding the anatomic site, our results showed that the upper limb was more frequently involved, accounting for over 73% of fractures. This finding aligns with studies conducted at a Sub-Saharan tertiary care center (7) and in the United States (22). In contrast, other studies have reported a higher incidence of lower limb involvement (19, 20). The increased incidence of upper limb fractures in our study may be attributed to the fact that 79% of children reported falls as the main cause, with the upper limb being more commonly injured during such incidents. When individuals fall, they instinctively use their upper limbs to protect themselves, which increases the likelihood of fractures. The arm, in particular, may be frequently involved due to its role as a protective mechanism during a fall.

The other finding of our study indicated that the radius is more commonly involved in the upper limb, this is supported by several studies (6, 20). In contrast, another study conducted at TASH & Italy found that the humerus is more frequently involved (10, 18). These discrepancies may arise from variations in the distribution of fractures across different studies and populations.

In this study, falls accounted for 79% of fracture mechanisms, making them the most common, followed by road traffic accidents (RTAs). This finding aligns with other studies (3, 18, 19, 24). The high incidence of fall-related fractures may be attributed to the various activities in which children engage, such as climbing, running, jumping, and playing, all of which increase the risk of falls.

Our study showed that bicycle riding (60.8%) and pedestrian activity (25%) are the most common modes of fracture. Regarding the location of the falls, surrounding playgrounds and homes account for the majority of cases. This finding is consistent with other studies (9, 20, 23, 24) and reflects the amount of time that preschool children spend at home, which may be greater than their active time spent outside.

The overall incidence of pediatric fractures among those who encountered trauma in selected hospitals during study period was 28%. Male children exhibited a higher incidence of fractures than female children. The highest risk of fractures occurred in children aged 6–10 years. Upper limb fractures were more frequently observed than lower limb fractures.