Global burden of pediatric fracture (1992-2021) and projections of future disease burden trends

Abstract

Objective

Pediatric fracture are a significant public health concern, contributing to both immediate health impacts and long-term disability. This study aims to quantify the burden of pediatric fracture over a 30-year period (1992-2021) and provide forecasts for future disease burden.

Methods

Comprehensive data on pediatric fracture from 1992 to 2021 were obtained from the Global Burden of Disease study. This dataset includes information on the incidence of pediatric fracture, disaggregated by gender. The Joinpoint regression model was used to identify turning points in epidemiological trends, while decomposition analysis helped identify the factors driving these trends. Health inequalities related to pediatric fracture were assessed using the Slope Index and Concentration Index. To forecast future incidence rates, the Norpred and BAPC models were applied.

Results

The global ASIR of pediatric fracture was 2225.38 in 1992 and 1531.44 in 2021. The total number of pediatric fracture globally was 39,436,228 in 1992 and 31,033,294 in 2021. The results of the Joinpoint regression indicate a declining trend in the incidence of pediatric fracture globally and in all SDI regions, for both male and female children. Based on the Nordpred and BAPC model, the predicted age-standardized incidence rate for pediatric fracture by 2046 is 1347.61-1349.43. The total number of pediatric fracture predicted by 2046 is 25,048,299-25,123,204.

Conclusion

Over the past three decades, the global incidence of pediatric fractures has declined. However, population growth has sustained a substantial disease burden, underscoring the necessity for effective prevention and management strategies.

Introduction

Pediatric fracture are among the most common injuries affecting children globally, with significant implications for both immediate health and long-term development [1]. They can lead to physical disabilities, psychological trauma, and a long-term burden on healthcare systems [2]. The global prevalence of pediatric fracture is rising, driven by increasing urbanization, changes in lifestyle, and growing participation in physical activities, including sports [3]. However, despite the growing recognition of pediatric fracture as a public health issue, comprehensive, global-scale data on the burden of these injuries over time remain scarce.

Understanding the burden of pediatric fracture is essential for designing effective interventions and resource allocation, particularly as fractures can have varying impacts depending on region, socioeconomic factors, and healthcare infrastructure [4]. In many regions, fractures contribute not only to morbidity but also to economic and social burdens due to medical costs, rehabilitation, and time lost from school or work [5]. Therefore, it is crucial to investigate the global epidemiological trends in pediatric fracture, assess the underlying causes of these injuries, and forecast future trends. Integrating global epidemiological trends and clinical research on pediatric fractures can inform further planning in pediatric orthopedics. A recent study comprehensively reviewed pediatric elbow fractures and dislocations, highlighting diagnostic challenges and emphasizing individualized management approaches based on fracture type and displacement severity [6]. Another study demonstrated the long-term efficacy and safety of elastic stable intramedullary nailing for tibial fractures over a 20-year period, reinforcing its value as a standard treatment approach for appropriate cases [7].

This study aims to fill the gap in knowledge by analyzing the global burden of pediatric fracture from 1992 to 2021, using data from the Global Burden of Disease (GBD) study [8]. By exploring the incidence of pediatric fracture, we aim to provide a comprehensive understanding of the current disease burden. Furthermore, we project future trends in pediatric fracture. Understanding these trends will guide the development of targeted interventions to reduce the future burden of pediatric fracture and enhance child health outcomes worldwide.

Methods

Materials

The 2021 Global Burden of Disease Study (GBD 2021) provides a comprehensive estimation of the incidence rates of pediatric fracture. These estimates are based on data collected during the GBD 2021 study, which can be accessed via the GBD Results Viewer at https://vizhub.healthdata.org/gbd-results/ [9]. The most recent access to this database was on December 26, 2024. The data sources for pediatric fracture include a diverse range of records from various countries, such as hospitalization data, emergency room visits, insurance claims, surveys, and vital registration systems [10].

The research utilized anonymized data compiled by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. The study protocol, including the waiver of informed consent, was reviewed and approved by the Institutional Review Board (IRB) of the University of Washington. The 2021 Global Burden of Disease Study (GBD 2021) provides a comprehensive analysis of 369 diseases and injuries, along with 87 associated risk factors, thoroughly examined across 204 countries and territories. The GBD research team has detailed their methodological approach and published age-standardized incidence rate (ASIR) estimates for these health conditions [11]. Based on the “Injuries by nature” category in the GBD 2021 database, we extracted the number of incident cases of fractures for three age groups: <5 years, 5–9 years, and 10–14 years. Using population data, we calculated the total number of incident cases and age-standardized incidence rate (ASIR, per 100,000 population) for pediatric fractures (0–14 years). Age-standardized incidence rates (ASIR, per 100,000 population) were calculated to enable comparisons across regions and time periods by accounting for variations in population age structures. Absolute numbers of incident cases were also reported to quantify the real-world public health burden, particularly for informing resource allocation (e.g., surgical capacity, rehabilitation services). This dual-metric approach aligns with Global Burden of Disease (GBD) reporting standards [12], where ASIR isolates epidemiological trends from demographic shifts, while absolute numbers reflect practical healthcare demands”.

To facilitate comparative analysis, the Global Burden of Disease project categorizes countries and regions based on their Socio-Demographic Index (SDI). This index classifies nations into five distinct SDI tiers: high SDI (>0.81), upper-middle SDI (0.70–0.81), middle SDI (0.61–0.69), lower-middle SDI (0.46–0.60), and low SDI (<0.46). This classification framework highlights both the commonalities and disparities in epidemiological patterns across different countries and regions [13].

Statistical analysis

Firstly, the incidence rates of fractures in children from three age groups (0–4, 5–9, and 10–14 years) by gender were obtained from the GBD database. The age-standardized incidence rates of pediatric fractures were then calculated based on the fracture incidence rates for these three age groups. A pyramid chart was used to visualize the fracture incidence rates by gender in the 0–4, 5–9, and 10–14 age groups. A world map was employed to visualize the age-standardized fracture incidence rates by gender globally in 1992 and 2021. Joinpoint regression analysis was performed using Joinpoint software to explore the inflection points in the trends of pediatric fracture incidence [14]. The age-period-cohort model was used to decompose the age, period, and cohort effects in the trends of pediatric fracture incidence [15]. Another age-period-cohort(APC) model developed by the Biostatistics Branch of the National Cancer Institute was used to analyze the trends in pediatric fracture incidence [16]. Decomposition analysis was employed to identify the driving factors behind the changes in the epidemiological trends of pediatric fractures [17]. The Slope Index of Inequality (SII) and Concentration Index (CI) were applied to assess whether gender-related health inequities exist in global pediatric fracture incidence in 2021 [18]. The Nordpred model and Bayesian age-period-cohort (BAPC) models were used to predict the age-standardized incidence rates and the number of pediatric fracture for the next thirty years, up to 2046, by sex [19]. Both Nordred and BAPC models are based on the Age-Period-Cohort (APC) model [20]. The theoretical basis of this model is that incidence or mortality is related to age structure and population size. The Nordpred model integrates age, period, and cohort effects with linear drift assumptions, using historical incidence rates (1992–2021) to extrapolate trends while accounting for population structure changes (GBD demographic projections) [21]. The BAPC model incorporated weakly informative priors to stabilize estimates for rare events, with Markov chain Monte Carlo (MCMC) sampling (4 chains, 10,000 iterations) to quantify uncertainty through 95% posterior prediction intervals [22].

All analyses in this study were conducted using R software (R Core Team, version 4.3.3, Vienna, Austria), with a P-value of less than 0.05 considered statistically significant.

Results

Global burden analysis from 1992 to 2021

The ASIR of pediatric fracture globally in 1992 was 2225.38 (1799.67–2710.84), with male children at 2326.77 (1896.59–2805.91) and female children at 2118.54 (1688.96–2618.52). In 2021, the age-standardized incidence rate of pediatric fracture globally was 1531.44 (1233.07–1870.29), with male children at 1565.02 (1275.08–1882.94) and female children at 1495.69 (1178.67–1860.97). The total number of pediatric fracture globally in 1992 was 39,436,228, with 21,207,580 in male children and 18,228,648 in female children. In 2021, the total number of pediatric fracture globally was 31,033,294, with 16,380,650 in male children and 14,652,644 in female children. Table 1 shows the incidence of pediatric fracture globally and in different SDI regions for 1992 and 2021. Figure 1 illustrates the distribution of fracture incidence by age group and gender worldwide. Figure 2 presents the global incidence of pediatric fracture in 1992 and 2021.

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Temporal trends in the epidemiology of pediatric fractures, 1992–2021

Based on Joinpoint Regression analysis, we identified a declining trend in the ASIR of pediatric fractures globally and across SDI regions from 1992 to 2021 The results of the Joinpoint regression indicate a declining trend in the incidence of pediatric fracture globally and in all SDI regions, for both male and female children. The Joinpoint regression results are presented in Fig. 3 and Table 2.

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Age-period-cohort model

The results of the age-period-cohort model suggest that, from 1992 to 2021, the global incidence of pediatric fracture increased with age, while the overall incidence of pediatric fracture showed a declining trend. However, in low SDI regions, boys aged 5–9 years and girls aged 0–4 years exhibited higher fracture incidence rates compared to other age groups. The results of the age-period-cohort model are presented in Table 3 and Fig. 4.

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APC model developed by the Biostatistics Branch of the National Cancer Institute

The results of the APC model developed by the Biostatistics Branch of the National Cancer Institute indicate that the age-standardized incidence rate of pediatric fracture increases with age. Additionally, the incidence of pediatric fracture has shown a declining trend over time. The results of this APC model are presented in Fig. 5.

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Decomposition analysis

The results of the decomposition analysis suggest that the overall trend in global pediatric fracture incidence is declining, with the primary driving factor for the increase in the number of cases being population growth. However, population growth primarily serves as the driving factor for the increase in pediatric fracture incidence in low SDI and low-middle SDI regions. In contrast, the overall trend in pediatric fracture incidence is clearly declining in high SDI, high-middle SDI, and middle SDI regions. The results of the decomposition analysis are presented in Table 4 and Figure S1.

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Health inequities

The Slope Index of Inequality (SII) for male pediatric fracture incidence in 2021 was 2163, while the SII for female pediatric fracture incidence in 2021 was 1921. The Concentration Index (CI) for male pediatric fracture incidence in 2021 was 0.12, and the CI for female pediatric fracture incidence was also 0.12. The statistical value of the F-test for comparing the CIs between different sexes for pediatric fracture incidence was 0.11, with a p-value of 0.73. The SII for pediatric fracture incidence in 1992 was 2336, and the SII for pediatric fracture incidence in 2021 was 2039. The CI for pediatric fracture incidence in 1992 was 0.18, while the CI for 2021 was 0.12. The statistical value of the F-test for comparing the CIs between different sexes for pediatric fracture incidence was 5.96, with a p-value of 0.015. The results of the health inequity analysis for pediatric fracture are presented in Figure S2.

Prediction of pediatric fracture

Based on the Nordpred model, the predicted age-standardized incidence rate for pediatric fracture by 2046 is 1349.43. Among these, the age-standardized incidence rate for male pediatric fracture is 1350.84, and for female pediatric fracture, it is 1347.94. The total number of pediatric fracture predicted by 2046 is 25,048,299, with 12,947,369 cases in boys and 12,100,930 cases in girls. Based on the BAPC model, the predicted age-standardized incidence rate for pediatric fracture by 2046 is 1347.61. Among these, the age-standardized incidence rate for male pediatric fracture is 1014.98, and for female pediatric fracture, it is 1133.09. The total number of pediatric fracture predicted by 2046 is 25,123,204, with 11,437,226 cases in boys and 13,685,979 cases in girls. The predictions for future pediatric fracture incidence are presented in Fig. 6, Appendix 2 and Appendix 3.

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Discussion

Our study suggests that, compared to 1992, the age-standardized incidence rate of pediatric fractures has decreased globally by 2021. Furthermore, despite global population growth, the total number of pediatric fractures has still declined, a trend observed in both boys and girls. The Joinpoint regression and age-period-cohort model further confirm that the trend of pediatric fractures is declining. The decline in pediatric fracture incidence may be related to several factors. First, over the past three decades (1992–2021), many countries have strengthened child safety and preventive measures, such as promoting the use of car seats, helmet-wearing, and improving safety design in children’s play areas [23]. These measures have contributed to a reduction in the incidence of accidents, thereby decreasing pediatric fracture rates [24]. Additionally, the widespread use of electronic devices over the past 30 years has led many children to spend more time indoors, reducing their participation in high-risk outdoor activities, and consequently lowering the likelihood of fractures [25]. Furthermore, with improvements in global public health, children in many countries have received more adequate intake of calcium and vitamin D, which supports bone development and health, further reducing the occurrence of fractures [26].

It is worth noting that in countries with low SDI (Socio-Demographic Index) regions, although the age-standardized incidence rates of pediatric fractures have declined, the total number of cases has significantly increased. Decomposition analysis of the changes in pediatric fracture incidence suggests that population growth is a positive driving factor for the increase in global pediatric fracture cases. However, when conducting a decomposition analysis of the pediatric fracture incidence trends across all SDI regions, it is found that population growth is the primary driver of the increase in pediatric fracture cases only in low-SDI and low-middle SDI regions. In these regions, the economic conditions and health awareness are relatively poor, and the promotion of safety measures, such as the use of car seats, may be insufficient [27]. Additionally, the level of child care may also be lacking [28]. Therefore, to further reduce pediatric fracture incidence, it is crucial to focus on increasing health resources and health education in low-SDI and low-middle SDI regions.

Our study suggests that pediatric fracture incidence increases with age, with older children (5–14 years) having a higher incidence than younger children (0–5 years). Compared to younger children, older children have more opportunities for outdoor activities and begin attending school, where they engage in group learning and activities. Many pediatric fractures occur within the school environment [29]. To reduce the incidence of fractures among older children, it is essential to further strengthen safety education within schools [30].

We also found that compared to 1992, both the slope index and concentration index of global pediatric fracture incidence decreased in 2021. Furthermore, the comparison of the concentration index showed statistically significant differences. In addition, there was no significant difference in the slope and concentration indices between boys and girls in 2021. These results suggest that the health inequities in global pediatric fractures have improved by 2021.

Using two predictive models, we project that by 2046, the ASIR of global pediatric fractures would continue to decline, reaching a range of 1347.61 to 1349.43. However, it is important to recognize that, despite this decline, the ongoing growth of the global population could still result in as many as 25,048,299 to 25,123,204 new pediatric fracture cases worldwide in 2046. A series of measures may be considered, including improving the safety of outdoor activity venues, wearing appropriate protective equipment, and preventing domestic violence [31].

Preventing the future disease burden in pediatric orthopedics is crucial [32]. Although declining incidence rates of fractures have been observed in both children and adults, pediatric fractures continue to impose a significant disease burden on populations [33]. Notably, timely and effective reduction of pediatric fractures is a current research priority [34]. Regardless of the fracture location, displaced fractures may impair patient function and contribute to severe disease burden [35]. Multidimensional interventions are needed to further reduce their incidence and long-term sequelae risks. The use of automated displacement grading models based on X-ray imaging and artificial intelligence to optimize closed reduction decision-making can mitigate malunion risks caused by delayed or suboptimal reduction [36]. In resource-limited settings, expedited referral and reduction guidance for complex cases can be achieved through telemedicine platforms, alleviating disease burden exacerbated by geographical barriers [37]. Minimally invasive surgery can also be considered for repositioning pediatric orthopedics [38].

This study utilized GBD data to analyze the overall burden of pediatric fractures, but it has several limitations. First, data availability significantly impacts the accuracy of GBD findings, as pediatric fractures in underdeveloped countries may be underdiagnosed or inadequately documented. Additionally, further exploration of risk factors for pediatric fractures is needed to better explain geographic disparities in their burden. In addition, data from early years or from countries and regions with lower levels of development may be inaccurate. Additionally, the exclusion of mortality and disability-adjusted life years (DALYs) in the analysis limits the comprehensiveness of disease burden characterization, leaving room for further refinement. These limitations should be considered when interpreting the results of this study.

Conclusion

Over the past three decades, the global incidence of pediatric fractures has declined. However, population growth has sustained a substantial disease burden, underscoring the necessity for effective prevention and management strategies.

Data availability

Data at national level can be found at: http://ghdx.healthdata.org/gbd-results-tool. All subnational level data used and analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ASIR:

Age-standardized incidence rate

ASPR:

Age-standardized prevalence rate

CI:

Confidence interval

YLDs:

Years Lived with Disability

EAPC:

Estimated annual percentage change

GBD:

Global Burden of Disease

SDI:

Socio-Demographic Index

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