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Background: Unintentional injuries are a major contributor to morbidity and healthcare burden in early childhood. While falls and fractures are globally recognized as the most common pediatric injuries, region-specific data from primary care emergency settings in Southeast Europe remain scarce. The objective was to investigate the mechanisms, anatomical distribution, and contextual factors of injuries in children aged 0 to 6 years treated in a primary care pediatric service in Bosnia and Herzegovina. Methods: This retrospective study included ninety-nine children aged 0 to 6 years who presented with injuries to a primary care service between September 2019 and December 2024. Data were collected from medical records and included age, sex, mechanism of injury, type of injury, anatomical site, supervision, home safety, and treatment outcome. Descriptive statistics and chi-square tests were used to analyze associations between demographic variables and injury characteristics. Logistic regression was also applied to examine predictors of fracture occurrence, adjusting for age group and sex. Results: Falls were the leading cause of injury, accounting for 69.7% of all cases, with the highest number recorded in the 13- to 36-month age group. Fractures were the most frequent injury type, of which 74.4% affected the upper limbs, particularly the radius and humerus. Head injuries were more prevalent among infants, while boys experienced a higher overall injury rate. No statistically significant associations were found between injury occurrence and supervision or home safety, largely due to missing data and limited sample size. Conclusion: Falls were the predominant cause of injury in early childhood, with upper limb fractures being common, especially among toddlers. While these findings provide important insights for prevention and pediatric emergency care planning in Bosnia and Herzegovina, larger prospective studies are needed to validate and extend these results.
KEYWORDS
Accidental Falls
Child
Preschool Fractures
Bone
Injury Prevention
Wounds and -
Injuries
Abstract:
Background: Unintentional injuries are a major contributor to morbidity and healthcare burden in early childhood. While falls and fractures are globally recognized as the most common pediatric injuries, region-specific data from primary care emergency settings in Southeast Europe remain scarce. The objective was to investigate the mechanisms, anatomical distribution, and contextual factors of injuries in children aged 0 to 6 years treated in a primary care pediatric service in Bosnia and Herzegovina.
Methods: This retrospective study included ninety-nine children aged 0 to 6 years who presented with injuries to a primary care service between September 2019 and December 2024. Data were collected from medical records and included age, sex, mechanism of injury, type of injury, anatomical site, supervision, home safety, and treatment outcome. Descriptive statistics and chi-square tests were used to analyze associations between demographic variables and injury characteristics. Logistic regression was also applied to examine predictors of fracture occurrence, adjusting for age group and sex.
Results: Falls were the leading cause of injury, accounting for 69.7% of all cases, with the highest number recorded in the 13- to 36-month age group. Fractures were the most frequent injury type, of which 74.4% affected the upper limbs, particularly the radius and humerus. Head injuries were more prevalent among infants, while boys experienced a higher overall injury rate. No statistically significant associations were found between injury occurrence and supervision or home safety, largely due to missing data and limited sample size.
Conclusion: Falls were the predominant cause of injury in early childhood, with upper limb fractures being common, especially among toddlers. While these findings provide important insights for prevention and pediatric emergency care planning in Bosnia and Herzegovina, larger prospective studies are needed to validate and extend these results.
Introduction
Unintentional injuries are among the leading causes of morbidity and mortality in childhood, contributing substantially to preventable deaths worldwide. The World Health Organization (WHO) estimates that injuries are responsible for over 875,000 deaths each year in children and young people under the age of eighteen.1 Childhood injuries occur at similar rates in both developed and developing countries. Understanding unintentional childhood injuries requires consideration of multiple factors, including the child's age, gender, history of prior injuries, maternal health and age, as well as environmental conditions.2 Childhood injuries are a frequent cause of hospitalization, even though they are mostly accidental and considered preventable.3 Injuries in childhood can be accompanied by softtissue and organ impairment, as well as bone fractures.4 Falls are the most common mechanism of injury, responsible for 17.5% of all injury-related deaths annually in a population up to 20 years of age.5 Anatomically, falls in early childhood typically involve the head and upper extremities, reflecting both developmental biomechanics and environmental hazards in the home, with infants particularly prone to cranial trauma due to their proportionally larger head and underdeveloped neck musculature, while fractures most often affect the distal radius and supracondylar humerus, regions particularly vulnerable to axial loading and biomechanical stress during impact.6, 7 These injuries are clinically important, as physeal involvement can disrupt longitudinal bone growth, potentially resulting in long-term deformity.8
Most childhood injuries occur at home, a setting typically perceived as safe, and often under parental supervision. Although largely preventable through safety education and environmental modifications such as cabinet locks, safety gates, and removing climbing hazards, these injuries can still lead to long-term disability, emotional trauma, and significant socioeconomic burden.4, 9 - 11 Some studies suggest that active parental involvement in infant care during the first six months has proven effective in preventing childhood injuries.12 A new WHO Europe pocketbook for primary health care of children and adolescents is being developed, with efforts made to identify the key evidence sources behind its recommendations. 13
Emergency Medical Services (EMS) play a crucial role in the initial assessment and stabilization of injured children, yet Bosnia and Herzegovina lacks a specialized pediatric EMS system. Establishing such a system would require dedicated equipment and trained pediatric professionals, whose current shortage contributes to gaps in pediatric trauma care.14,15
Despite the global burden, data from Southeast Europe remains limited. In Bosnia and Herzegovina, systematic registration of childhood injuries in primary health care began only in 2021, revealing that injuries were most often sustained at home (42.2%), while the lowest frequency was reported in infants under one year (0.7%, 256 cases).16 However, no comprehensive pediatric injury registry exists, limiting prevention strategies and emergency preparedness.
The present study aimed to investigate mechanisms, anatomical distribution, and contextual factors of injuries in children aged 0 - 6 years presenting to a primary care pediatric service in Gračanica, Bosnia and Herzegovina, with the goal of informing evidence-based prevention strategies.
Methods
This study is a retrospective, descriptive analysis of pediatric injuries treated at the Primary Healthcare Center Gračanica, Bosnia and Herzegovina. The study included ninety-nine children aged 0 to 6 years who presented with any form of injury between September 2019 and December 2024. The inclusion criteria consisted of children with complete medical records for age, sex, type of injury, mechanism, anatomical injury site, and outcome. Cases with incomplete data were excluded.
Children's age was stratified into three groups: 0- 12 months, 13-36 months, and 37-72 months. Anatomical regions of injury were categorized as upper limb, lower limbs, skull, face, thorax, abdomen, or other. Injury types were classified as fracture, laceration, contusion, burn, bite, foreign body, poisoning, and trafficrelated injury. Parental age was analyzed as both a continuous variable and in categories (<20, 20-29, 30- 39, ≥40 years). Parental supervision at the time of injury was recorded as present, absent, or unknown, while documentation of home safety measures was extracted from caregiver reports when available.
Descriptive statistics were used to summarize demographic data, injury characteristics, and contextual factors. Chi-square tests were applied to assess associations between categorical variables. Logistic regression was additionally performed to explore predictors of fracture occurrence, adjusting for sex and age group. To maintain an adequate events-per-variable ratio, only these core covariates were included, while other potential predictors, such as parental education, supervision, and home safety, were not modeled due to a small sample size and substantial missingness. However, due to the relatively small sample size and low event counts in several injury categories, robust multivariable modeling was not feasible for all outcomes. Therefore, descriptive statistics and chi-square tests remained the primary analytical approaches. The study was designed and reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.17
The study was conducted in accordance with the Helsinki Declaration. Ethical approval was obtained from the Ethics Committee of the Primary Healthcare Centre Gračanica. As this was a retrospective study using anonymized medical records, the requirement for individual informed consent was waived.
Results
The study included ninety-nine children aged 0 to 6 years, with a slightly higher proportion of boys. Injuries were most frequent among toddlers aged 13-36 months. Most parents were in their thirties, and no parents were under the age of 20. Sociodemographic characteristics of the study population are presented in Table 1.
The most common mechanism of injury was falling, which accounted for 69 cases (69.7%). Falls were the leading cause of injury across all age groups: 76.9% in children aged 0-12 months, 63.5% in the 13-36 month group, and 79.4% in the 37-72 month group. Other mechanisms included being struck by an object (n = 12; 12.1%), burns (n = 2; 2.0%), foreign object injuries (n = 3; 3.0%), bites (n = 2; 2.0%), traffic-related incidents (n = 2; 2.0%), poisoning (n = 2; 2.0%), and unknown causes (n = 6; 6.1%) (Figure 1).
The distribution of injury mechanisms was compared between boys and girls. Falls were the leading mechanism for both sexes; however, they occurred slightly more frequently among boys (72.2%) than girls (66.7%). Other mechanisms occurred sporadically and showed no clear sex-based pattern. A chi-square test revealed no statistically significant association between sex and mechanism of injury (p = 0.972).
The most frequently affected anatomical region was the upper limb, with 39 cases (39.4%), followed by the head with 32 cases (32.3%) and the lower limb with 19 cases (19.2%). Injuries to the thorax, abdomen, and face were rarely recorded, each accounting for fewer than 3% of all cases. Upper limb injuries were most common among children aged 4-6 years (52.9%), whereas head injuries were most frequent in infants aged 0-12 months (53.8%). Lower limb injuries showed a more even distribution across age groups. No statistically significant association was found between age group and injured body region (p = 0.464), nor between sex and anatomical injury region (p = 0.921) (Figure 2).
Among all recorded injuries, fractures were the most frequent type, reported in 39 children (39.4%). Fractures were more prevalent in older age groups, particularly in children aged 4-6 years (n = 18). The second most common type of injury was contusions (n = 25; 25.3%), with the majority occurring in children older than 1 year (n = 18). Lacerations and cuts followed (n = 22; 22.2%). Other types of injuries were less frequent, including dislocations and sprains (n = 5; 5.1%), bite wounds (n = 2; 2.0%), thermal injuries (n = 2; 2.0%), foreign body injuries (n = 2; 2.0%), and poisonings (n = 2; 2.0%) (Table 2).
An exploratory analysis was conducted to examine the distribution of fractures and other types of injuries across anatomical regions. Of the 39 fractures recorded, nearly three-quarters involved the upper limbs (n = 29; 74.4%), most frequently affecting the radius, humerus, and clavicle. Lower limb fractures accounted for 20.5% (n = 8), while skull fractures were rare (n = 2; 5.1%). Fractures were more frequent among boys (n = 24; 61.5%) than girls (n = 15; 38.5%). The mean age of children with fractures was highest for upper limb injuries (39 months), compared to lower limb (36.5 months) and skull fractures (24.5 months). Statistical testing showed no significant association between sex and anatomical region of fracture (p = 0.343) (Table 3). Other injury types displayed different anatomical patterns: lacerations and contusions were most often associated with head injuries, particularly in infants and toddlers; burn injuries were confined to the upper body; while foreign body injuries, bites, and poisonings occurred sporadically across sites and age groups. Subgroup sizes were small, precluding further statistical analysis. As an exploratory multivariable approach, we additionally conducted a logistic regression model adjusted for age group and sex to examine predictors of fracture occurrence.
Logistic regression was performed to investigate whether sex and age group were predictors of fracture occurrence. Neither factor reached statistical significance. Compared with children aged 0-1 year, the odds of fracture were 1-3 years: OR = 1.09 (95% CI 0.29-4.06; p = 0.895) and 4-6 years: OR = 2.53 (0.65-9.83; p = 0.180). Male sex showed higher odds compared to female sex: OR = 1.60 (0.70-3.63; p = 0.261) (Table 4).
Regarding contextual injury factors, parental supervision was reported to be present at the time of injury in 36 cases (36.4%), absent in 25 cases (25.3%), and unknown in 38 cases (38.4%). Safety measures in the household were reportedly present in only 7 cases (7.1%), absent in 38 cases (38.4%), while in more than half of the cases (54.5%), this information was not available or not recorded. The high proportion of missing data on home safety measures limited meaningful statistical analysis of these contextual factors.
When looking at the distribution of injuries across the study period, only one case was reported in late 2019, followed by a gradual increase: 9 in 2020, 18 in 2021, 19 in 2022, and 15 in 2023. The highest number of injuries was recorded in 2024, with 37 cases (37.4%).
Discussion
This study found that falls were the predominant cause of injury in children under six, most often resulting in upper limb fractures, particularly among toddlers.
In our study, the largest number of fall-related injuries was observed in the 13-36 month age group. This finding is consistent with other studies indicating that toddlers are particularly vulnerable to falls due to their developmental stage. During this period, children are rapidly gaining mobility by walking, climbing, and exploring their environment while still lacking fully developed balance, coordination, and risk awareness.18, 19 Anatomically, children in this age range have a high center of gravity and underdeveloped protective reflexes, which increases their likelihood of falling and sustaining injuries, especially to the upper limbs and head.20
Our data shows that falls were significantly more frequent among boys than girls, which is in line with findings from other studies.21-23 Male children accounted for the majority of fall-related injuries across all age groups. This sex-based disparity has been well documented in pediatric trauma research and is commonly attributed to higher levels of physical activity, impulsivity, and risk-taking behavior observed in boys.24,25 These behavioral tendencies, combined with developing motor control and limited hazard perception, likely explain the greater frequency of falls in male children. In our study, fractures represented the most frequent injury, and over 70% of these involved the upper extremity, primarily the radius, humerus, ulna, and clavicle. These findings are consistent with previous research, which has identified upper limb fractures as the most frequent skeletal injuries in early childhood.26, 27 In particular, fractures of the radius and humerus were predominant in our study population, often resulting from fall-related trauma. Anatomically, this is explained by the fact that children instinctively use their arms to break a fall. The distal radius, with its thinner cortical bone and high biomechanical stress during impact, is especially susceptible to buckle and greenstick fractures.28 The humerus, particularly its supracondylar region, is also prone to fracture in preschool-aged children due to its vulnerable shape and proximity to the elbow joint, a common site of transmission of axial forces during falls.29 In contrast, lower limb injuries were less frequent and typically involved the tibia and femur, often resulting from running, tripping, or falling from elevated surfaces like stairs or play equipment. While the head was not the most frequently injured region overall, it was more commonly affected in younger children, particularly infants and toddlers. This reflects wellestablished anatomical principles, that the head is proportionally larger in early life, the center of gravity is higher, and neck musculature is underdeveloped, making head-first impacts more likely and more serious even from low heights.30 Furthermore, the scalp's rich vascular supply in children often results in dramatic bleeding, leading to increased medical attention even for superficial injuries.31 Less frequent mechanisms of injury included burns, foreign bodies, bites, poisoning, and traffic-related trauma. Burns were limited to the upper body, typically from hot liquids such as boiling water or coffee. This finding is consistent with previous studies that highlight scald burns as the most common type of thermal injury in young children, often occurring in domestic settings like kitchens or dining areas.32-34 Foreign body injuries and poisonings are characteristic of exploratory behaviors in toddlers. Bite injuries, though rare, involve both animal and human sources and align with prior research showing that children are more likely to sustain bites during close-contact play or in homes with pets.35 Although there were a few trafficrelated injuries, their presence highlights the necessity for a better education for families regarding road safety and passive restraint systems.
An important aspect of pediatric injury prevention involves the presence of paternal supervision and the implementation of home safety measures. In our study, supervision was reported as present in 36.4% of cases, absent in 25.3% and unknown in 38.4%. Similarly, safety measures in the home were reported as present in only 7.1% of cases, but 54.5% of records lacked this information. The absence of a significant association between supervision or taking home safety measures and injury occurrence should be interpreted with caution, as the high proportion of missing data substantially limits the validity of this analysis. Nevertheless, prior studies have consistently shown that active supervision reduces injury risk, particularly in younger children, and that the presence of environmental safety modifications can significantly decrease injury incidence in the home.36 These findings underscore the need for community-level education and primary care counseling on ageappropriate supervision and household hazard reduction in pediatric injury prevention.
Over the five-year study period, injury cases progressively increased, peaking in 2024. This trend may reflect greater parental awareness and healthcare access, shifts in routines and supervision during and after the COVID-19 pandemic, or a real rise in exposure to household and community hazards, especially in urban settings with limited safe play areas. Similar studies have reported fewer pediatric emergency visits during lockdowns but higher proportions of fractures and domestic accidents.37 The observed increase underscores the need for preventive strategies and public health education for caregivers of young children.
This study has several limitations. The relatively small sample size (99 cases over five years) reduced statistical power and limits generalizability, which may explain the lack of significance in some comparisons. The study period coincided with the COVID-19 pandemic, during which restrictions on mobility and healthcare access led to a reduction in the number of reported cases. Being conducted in a smaller community in Bosnia and Herzegovina, where pediatric injury surveillance is less established, also limits extrapolation. The focus on children under six years prevents generalization to older pediatric groups but addresses an important gap in the literature. Missing data on supervision and household safety further constrained the analysis of contextual risk factors. Although we performed a logistic regression model adjusting for age and sex, the limited number of fracture events and the high proportion of missing contextual data prevented the inclusion of additional covariates such as parental education, supervision, or household safety. Consequently, residual confounding cannot be excluded. More systematic documentation, including supervision, environmental hazards, and safety measures, is needed in future research. Larger, multicenter prospective studies are warranted to validate and expand on these findings.
Authors' Contributions:
E.M. designed the study, A.T. participated in data collection, E.M., M.B. and E.B. analyzed and interpreted the data, E.M., M.B. and E.B. supervised all the work, E.M., A.T., M.B., E.B., E.Z., A.M. prepared the draftand revised it. All authors reviewed and approved the final version.
Funding: None.
Competing interests: None declared.
Ethical approval: This study was conducted under institutional research ethics standards, and formal ethics committee approval was obtained, number: 02-67- 2/25.
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* Corresponding Author at:
Elma Mujakovié: MD, Department of Anatomy, Faculty of Medicine, University of Tuzla Univerzitetska 1, 75000 Tuzla, Bosnia and Herzegovina, Phone: +38735320421, E-mail: [email protected] (Mujakovié E.). https: / /orcid.org/0009-0006-7854-097 3
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