The impact of individual and regional socioeconomic identity on pediatric extremity fracture management: A scoping review.

BACKGROUND: Pediatric extremity fractures represent a frequent cause of emergency department visits, with inequity in care linked to socioeconomic status, race, and insurance type. Despite standardized treatment algorithms, currently available evidence indicates that socially disadvantaged children experience delays in surgical fixation and pain management. This scoping review aims to evaluate the impact of socioeconomic factors on multiple elements of pediatric extremity fracture management.

METHODS: This scoping review followed PRISMA standards. Eligible studies included pediatric patients (<18 years) with extremity fractures, incorporated measures of social or economic status, and evaluated pre-defined management outcomes. Studies conducted before 2010 or outside of the United States were excluded. Abstracts and full texts were screened independently by multiple reviewers using Covidence software.

RESULTS: After duplicate removal, 9,671 articles were screened, with 78 undergoing full-text review; 33 articles met all inclusion criteria. The 33 eligible studies predominantly consisted of retrospective cohort analyses, with sample sizes ranging from fewer than 500 to over 9 million patients. Major outcomes evaluated included type of treatment offered (n=10), pain management (n=10), time to care (n=8), post-discharge care (n=4), imaging (n=3), and pre-hospital care (n=1). Inequities were identified across multiple domains, commonly associated with insurance status, race, family income, and primary language. Children with public insurance consistently experienced higher rates of nonoperative management and longer delays to definitive treatment. Racial/ethnic minority children had lower odds of receiving opioid analgesics despite equivalent pain levels.

DISCUSSION AND CONCLUSION: Socioeconomic disadvantage, measured at both the individual and regional level, is strongly associated with differences in pediatric extremity fracture management, including inequitable access to timely imaging, operative care, and adequate pain control. These findings underscore the critical need for targeted policy interventions, standardized clinical protocols, and improved care coordination to reduce disparities and ensure equitable pediatric fracture care for all children.