Justin Le, OMS-II¹; Nicholas Moscardelli, OMS-II¹; Isha Shashi, OMS-I¹; Anter Gonzales, MD^2 
1Rowan-Virtua School of Osteopathic Medicine, Stratford, NJ, 0009-0008-6434-7931
²Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, NY/Orthopaedic Institute Brielle Orthopaedics, Brick, NJ

STATEMENTS AND DECLARATIONS
The authors disclose no relevant conflicts of interest related to this study.

FUNDING
No funding was sought for this study.

ABSTRACT

Background
Lower-extremity fractures sustained during sports participation are common in pediatric populations, yet the risk of hospital admission varies substantially by anatomic fracture location. National data examining how fracture location influences emergency department (ED) admission are limited. In this study, we conducted a retrospective cross-sectional study using the U.S. CPSC NEISS database to evaluate the association between lower-extremity fracture location and ED disposition among pediatric sports-related injuries.

Methods
We conducted a retrospective cross-sectional study using data from the National Electronic Injury Surveillance System (NEISS) from 2015 to 2024. Pediatric patients aged 10-18 years presenting with sports-related lower-extremity fractures were included. Fractures were categorized into five anatomic locations: femur/hip, knee/patella, lower leg (tibia/fibula), ankle, and foot/toes. The primary outcome was ED disposition, defined as hospital admission or observation versus discharge. Survey-weighted descriptive analyses and logistic regression were performed to generate nationally representative estimates, adjusting for age and sex.

Results
A total of 12,528 encounters met inclusion criteria, representing an estimated 323,448 injuries nationally. The cohort was predominantly male (82.5%), with a mean age of 14.16 years. Overall, 9.0% of fractures resulted in admission or observation. Admission rates varied substantially by fracture location, ranging from 0.33% for foot/toe fractures to 53.66% for femur/hip fractures. Compared with foot/toe fractures, femur/hip, lower-leg tibia or fibula, knee/patella, and ankle fractures were associated with significantly lower odds of ED discharge (all p < 0.001). Increasing age was associated with higher likelihood of admission, while male sex was associated with higher odds of discharge.

Conclusion
Among pediatric sports-related lower-extremity fractures, anatomic fracture location is a strong predictor of ED disposition. Proximal fractures, particularly those involving the femur or hip, are associated with substantially higher admission rates compared with distal injuries.

Keyword(s): pediatric fracture, sports-related injuries, fracture location, lower extremity

INTRODUCTION
Emergency departments (EDs) in the United States manage a large volume of pediatric lower-extremity (LE) injuries each year, many of which occur during organized or recreational sports activities. Among these, fractures involving the hip, knee, femur, tibia, and ankle represent some of the most severe pediatric sports-related injuries and are associated with higher rates of surgical intervention than fractures sustained outside of athletic contexts (1). Sports participation accounts for approximately one-third of all pediatric fractures, with an estimated 3-5 fractures per 1,000 children presenting to the ED annually (2,3). Injury rates vary substantially by sport, with football, basketball, soccer, and baseball responsible for nearly three-quarters of reported sports-related injuries, and males comprising the majority of affected patients (4,5).

The clinical severity of pediatric LE fractures is influenced by both fracture location and the risk of associated complications, which can substantially impact patient outcomes and utilization of healthcare resources. Proximal fractures involving the femur and hip are associated with serious complications including compartment syndrome, neurovascular injury, venous thrombosis, and avascular necrosis of the femoral head (6-8). These complications can further progress into significant long-term disability, and disruption to the lives of children and their caregivers (6,9).

Over recent decades, operative management of pediatric LE fractures have increased alongside advances in fixation techniques and perioperative care. Contemporary pediatric orthopedic practice emphasizes treatment strategies based on patient age, fracture location, stability, and social considerations, with particular attention to soft-tissue protection and complication avoidance (10-12). Conversely, modern surgical techniques such as elastic stable intramedullary nailing have demonstrated favorable risk-benefit profiles and may reduce recovery time compared with prolonged immobilization in appropriately selected patients (9). Emerging evidence further suggests that the timing of operative intervention, particularly for femoral shaft fractures, may not be the primary determinant of outcomes, as immediate fixation does not appear to significantly influence union rates or long-term functional status when compared with delayed intervention (13).

Despite these advances, substantial gaps remain in understanding optimal management strategies for pediatric sports-related LE fractures. Existing studies are predominantly retrospective, single-center investigations with limited sample sizes and heterogeneous patient populations (9,14). To date, large-scale national analyses evaluating how anatomic fracture location influences hospital admission and observation patterns among pediatric patients sustaining sports-related LE fractures remain limited. Therefore, using the National Electronic Injury Surveillance System (NEISS) database, this study aims to characterize hospital admission rates across anatomic locations of sports-related LE fractures in U.S. pediatric patients aged 10-18 years. We hypothesize that proximal lower-extremity fractures characterized as (hip/femur and knee/patella) are associated with significantly higher hospital admission rates compared with distal fractures involving the ankle and foot/toes, independent of patient age and sex.

METHODS

Study Design and Data Source
This was a retrospective cross-sectional study utilizing data from the National Electronic Injury Surveillance System (NEISS), a nationally representative emergency department surveillance database maintained by the U.S. Consumer Product Safety Commission (CPSC). Each case includes patient demographics, injury diagnosis, body part involved, product codes, ED disposition, and survey design variables including sampling weights, strata, and primary sampling units (PSUs). All NEISS data is publicly available and de-identified, and therefore, no institutional review board (IRB) was needed. Queries were performed between January 1, 2015 to December 31, 2024.

Study Population
We identified pediatric patients aged 10 to 18 years who presented to participating U.S. emergency departments with a fracture involving the lower extremity. Fractures were defined using the NEISS diagnosis code for fracture (57). To restrict the cohort to sports-related injuries, cases were included only if the primary product code corresponded to organized or recreational sports activities for these common sports: baseball/softball (1204/3240/3270/5041/5034), basketball (1205/3226/3242), football (1211/3244), hockey (1295/3272/5032), tennis (3284), soccer (1267/3241/3271), track and field activities (1268/5030), and volleyball (1266/3220). Injuries involving non-lower-extremity body parts, non-fracture diagnoses, patients outside the specified age range, or cases with missing ED disposition were excluded.

Exposure Variable: Lower-Extremity Fracture Location
The primary variable was anatomic fracture location within the lower extremity, categorized using NEISS body part codes. These included knee (35), lower leg (36), ankle (37), upper leg (81), foot (83), and 93(toe). These were then grouped into five mutually exclusive categories: femur/hip (91), knee/patella (35), lower leg (tibia/fibula) (36), ankle (37), and foot/toes (83/93).

Outcome Measure
The primary outcome was ED disposition, operationalized as a binary indicator of hospital admission or observation versus discharge. Patients who were admitted to the hospital or placed under observation were classified as admitted/observed, while those treated and released from the ED were classified as discharged. ED disposition was used as a proxy measure of injury severity and resource utilization.

Statistical Analysis
All analyses accounted for the complex sampling design of NEISS using sampling weights, hospital strata, and PSUs to produce nationally representative estimates and valid variance calculations. Descriptive statistics were generated to summarize patient characteristics and admission rates by fracture location, with results reported as weighted estimates and standard errors. Survey-weighted logistic regression was used to evaluate the association between lower-extremity fracture location and the likelihood of hospital admission or observation, adjusting for age and sex. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were reported. Because of model parameterization, odds ratios less than 1 indicate lower odds of ED discharge and therefore higher likelihood of admission or observation. Statistical significance was defined as a two-sided p value < 0.05. All statistical analyses were performed using IBM SPSS Statistics (31.0.0.0) with the Complex Samples module.

RESULTS

Study Cohort
A total of 12,528 pediatric emergency department encounters met inclusion criteria, representing an estimated 323,448 sports-related lower-extremity fracture visits nationally within the past 10-years (2015-2024). The cohort was predominantly male, accounting for approximately 82.5% of injuries, with a mean age of 14.16 years. Overall, 9.0% of pediatric sports-related lower-extremity fractures resulted in hospital admission or observation, while 91.0% were treated and discharged from the emergency department. See Table 1.

Fracture Location Distribution
Fracture distribution varied substantially by anatomic location. Ankle fractures were the most common injury, comprising 32.8% of cases, followed by lower-leg fractures involving the tibia or fibula, 30.8%. Femur or hip fractures accounted for 3.4% of cases, while foot or toe fractures represented 26.5% and knee/patellar fractures 6.4% of injuries. See Table 2.

Admission Rates by Fracture Location
Weighted admission or observation rates differed markedly across fracture locations (Figure 1). Admission rates were lowest for foot or toe fractures (0.33%) and ankle fractures (4.35%). In contrast, substantially higher admission rates were observed for knee or patellar fractures (13.30%) and lower-leg tibia or fibula fractures (15.72%). Femur or hip fractures were the most serious injuries requiring the highest rate of admission (53.66%). See Table 2.

Association Between Fracture Location and Admission
In survey-weighted logistic regression adjusting for age, sex, and injury location, fracture location was strongly associated with emergency department disposition (Table 2). Using foot/toe fractures as the reference group, progressively more proximal fractures demonstrated significantly lower odds of emergency department discharge, corresponding to a higher likelihood of hospital admission or observation. Compared with foot/toe fractures, femur or hip fractures had the lowest odds of discharge (OR 0.003, 95% CI 0.002-0.004, p < 0.001), followed by lower-leg tibia or fibula fractures (OR 0.022, 95% CI 0.013-0.037, p < 0.001), knee or patella (OR 0.018, 95% CI 0.011-0.031, p < 0.001), and ankle fractures (OR 0.076, 95% CI 0.043-0.135, p < 0.001). See Table 3.

Increasing age was independently associated with lower odds of emergency department discharge (OR, 0.94 per year; 95% CI, 0.90-0.98; p = 0.009), indicating a higher likelihood of hospital admission or observation with advancing age. Male sex was independently associated with higher odds of discharge compared with female sex (OR, 1.98; 95% CI, 1.54-2.56; p < 0.001).

DISCUSSION
This study demonstrates a consistent association between anatomic fracture location and ED disposition among pediatric sports-related lower-extremity fractures. Using ten years of NEISS data, a proximal-to-distal gradient in admission and observation rates was observed, with femur and hip fractures associated with higher rates of hospital admission or observation compared with more distal injuries involving the ankle or foot. After adjustment for age and sex, progressively proximal fractures remained less likely to be discharged from the ED, suggesting that fracture location is associated with differences in initial management and resource utilization. Although this proximal-to-distal pattern is clinically intuitive, its value lies in quantifying this relationship at a national level using a large, injury surveillance dataset and demonstrating that it persists across at the pediatric level.

These findings are consistent with prior epidemiologic and clinical studies reporting higher injury severity and increased inpatient management among children with proximal LE fractures. Femur and hip fractures have been associated with greater risk of complications such as neurovascular injury and avascular necrosis, which may contribute to higher admission rates reported in clinical series (7,8,15). The admission proportion observed for femur and hip fractures in this study is similar to patterns described in contemporary orthopedic literature (9,10). In contrast, ankle and foot fractures demonstrated low admission rates, consistent with reports that many distal LE fractures in children can be managed in the outpatient setting (6,14,16).

Admission rates for tibia/fibula and knee/patella fractures were intermediate, which may reflect the heterogeneity of these injury categories. Tibial fractures encompass a broad range of injury patterns and treatment approaches, from minimally displaced fractures treated nonoperatively to high-energy injuries requiring operative intervention (11,17). Similarly, knee and patellar fractures may prompt admission due to concerns for extensor mechanism injury or associated intra-articular pathology (7). Notably, these findings suggest that fracture location alone, even without detailed radiographic characterization, is associated with differences in ED disposition at a population level. Overall, the observed relationship between fracture location and admission likelihood may be useful for contextualizing patterns of care in pediatric sports trauma and for informing future research on injury severity and healthcare utilization. At the population level, relatively uncommon injuries such as femur and hip fractures accounted for a disproportionate share of admissions among pediatric sports-related lower-extremity fractures, consistent with prior national injury surveillance studies (5,18).

Several limitations should be considered. As with all NEISS-based studies, the dataset lacks clinical granularity, including detailed fracture classification, displacement, imaging findings, operative management, and long-term outcomes. To address this limitation, our analysis focused on a clearly defined and consistently recorded outcome, ED disposition, allowing for standardized comparison across fracture locations in a large, nationally representative sample. Because of these constraints, admission or observation status should be interpreted as an indirect proxy for injury severity rather than a definitive clinical outcome. Additionally, ED disposition may be influenced by institutional practice patterns and nonclinical factors. Nevertheless, the large sample size, use of survey-weighted national estimates, and the consistency of the proximal-to-distal gradient across fracture sites support the robustness and generalizability of the observed associations within the scope of our study objective, which was to characterize population-level patterns in pediatric sports-related injuries in admission rates by fracture location.

CONCLUSION
Anatomic fracture location was associated with differences in ED disposition among pediatric sports-related LE fractures. A proximal-to-distal gradient in admission rates was observed over a decade of nationally representative data. While these findings align with clinical expectations, they offer population-level characterization of disposition patterns across fracture sites. Additional studies with more granular clinical detail are needed to clarify how fracture characteristics influence management decisions.

REFERENCES

1. Cordonnier T, Germon V, Lemé C, Jouve JL, Launay F, Pesenti S: Frequent location and severity of sports-related fractures in children in a tertiary care-center. A retrospective observational cohort study. Orthop Traumatol Surg Res. 2025, 111:104327. 10.1016/j.otsr.2025.104327
2. Randsborg PH, Gulbrandsen P, Saltytė Benth J, et al.: Fractures in children: epidemiology and activity-specific fracture rates. J Bone Joint Surg Am. 2013, 95:e42. 10.2106/jbjs.L.00369
3. Naranje SM, Erali RA, Warner WC, Jr., Sawyer JR, Kelly DM: Epidemiology of Pediatric Fractures Presenting to Emergency Departments in the United States. J Pediatr Orthop. 2016, 36:e45-48. 10.1097/bpo.0000000000000595
4. Bayt DR, Bell TM: Trends in paediatric sports-related injuries presenting to US emergency departments, 2001-2013. Inj Prev. 2016, 22:361-364. 10.1136/injuryprev-2015-041757
5. Burt CW, Overpeck MD: Emergency visits for sports-related injuries. Ann Emerg Med. 2001, 37:301-308. 10.1067/mem.2001.111707
6. Metaizeau JD, Denis D: Update on leg fractures in paediatric patients. Orthop Traumatol Surg Res. 2019, 105:S143-s151. 10.1016/j.otsr.2018.02.011
7. Herman MJ, Martinek MA, Abzug JM: Complications of tibial eminence and diaphyseal fractures in children: prevention and treatment. J Am Acad Orthop Surg. 2014, 22:730-741. 10.5435/jaaos-22-11-730
8. Mittal MM, Acevedo KV, Hosseinzadeh P: Risk of Venous Thromboembolism in Pediatric Patients with Surgically Treated Lower-Extremity Fractures: A Propensity-Matched Cohort Study. J Bone Joint Surg Am. 2025, 107:1171-1179. 10.2106/jbjs.24.00810
9. Madhuri V, Dutt V, Gahukamble AD, Tharyan P: Interventions for treating femoral shaft fractures in children and adolescents. Cochrane Database Syst Rev. 2014, 2014:Cd009076. 10.1002/14651858.CD009076.pub2
10. Gordon JE, Mehlman CT: The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Femoral Shaft Fracture Pearls and Pitfalls. J Orthop Trauma. 2017, 31 Suppl 6:S16-s21. 10.1097/bot.0000000000001016
11. Hogue GD, Wilkins KE, Kim IS: Management of Pediatric Tibial Shaft Fractures. J Am Acad Orthop Surg. 2019, 27:769-778. 10.5435/jaaos-d-17-00819
12. Lindsay SE, Holmes S, Swarup I, Halsey M: Trends in Management of Pediatric Distal Radius Buckle Fractures. J Pediatr Orthop. 2022, 42:367-371. 10.1097/bpo.0000000000002169
13. Hidalgo Perea S, Loyst RA, Botros D, Barsi JM: Outcomes in Early Versus Delayed Management of Pediatric Femoral Shaft Fractures. J Pediatr Orthop. 2024, 44:e238-e241. 10.1097/bpo.0000000000002598
14. Rickert KD, Hosseinzadeh P, Edmonds EW: What’s New in Pediatric Orthopaedic Trauma: The Lower Extremity. J Pediatr Orthop. 2018, 38:e434-e439. 10.1097/bpo.0000000000001209
15. Greenhill DA, Herman MJ: Treatment of Pediatric Femoral Shaft Fractures. J Am Acad Orthop Surg. 2022, 30:e1443-e1452. 10.5435/jaaos-d-22-00415
16. Boutin A, Colaco K, Stimec J, et al.: Removable Boot vs Casting of Toddler’s Fractures: A Randomized Clinical Trial. JAMA Pediatr. 2025, 179:713-721. 10.1001/jamapediatrics.2025.0560
17. Villarreal ED, Wrenn JO, Sheffer BW, Sawyer JR, Spence DD, Kelly DM: Do Patient-specific or Fracture-specific Factors Predict the Development of Acute Compartment Syndrome After Pediatric Tibial Shaft Fractures? J Pediatr Orthop. 2020, 40:e193-e197. 10.1097/bpo.0000000000001410
18. Orces CH, Orces J: Trends in the U.S. Childhood Emergency Department Visits for Fall-Related Fractures, 2001-2015. Cureus. 2020, 12:e11629. 10.7759/cureus.11629