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The Association Between Fracture Rates and Neighborhood Characteristics in Washington, DC, Children
  1. Leticia Manning Ryan, MD, MPH*†,
  2. Mark Guagliardo, PhD,
  3. Stephen J. Teach, MD, MPH*†,
  4. Jichuan Wang, PhD,
  5. Jennifer E. Marsh, PhD, JD,
  6. Steven A. Singer, MD,
  7. Joseph L. Wright, MD, MPH*†§,
  8. James M. Chamberlain, MD*†
  1. From the *Division of Emergency Medicine and †Center for Clinical and Community Research, Children’s National Medical Center; ‡Department of Emergency Medicine, George Washington University Medical Center; and §Child Health Advocacy Institute, Children’s National Medical Center, Washington, DC.
  1. Received March 21, 2012, and in revised form November 8, 2012.
  2. Accepted for publication November 10, 2012.
  3. Reprints: Leticia Manning Ryan, MD, MPH, Division of Emergency Medicine, Center for Clinical and Community Research, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC 20010. E-mail: lryan{at}
  4. Supported in part by the National Institutes of Health National Center for Research Resources (1K23 RR024467-01) and the Children’s National Medical Center Children’s Research Institute Research Advisory Council Grant.
  5. Presented at the Pediatric Academic Societies Annual Meeting, 2009, Baltimore, MD.
  6. The authors have no conflicts of interest related to this article to disclose.
  7. Dr Guagliardo is currently affiliated with JG Analytics, LLC, Burke, VA.
  8. Dr Marsh is currently affiliated with Office of Medical Services, Peace Corps Headquarters, Washington, DC.
  9. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (


Background Effects of neighborhood contextual features have been found for many diseases, including bone fractures in adults. Our study objective was to evaluate the association between neighborhood characteristics and pediatric bone fracture rates. We hypothesized that neighborhood indices of deprivation would be associated with higher fracture rates.

Materials and Methods Pediatric bone fracture cases treated at a tertiary, academic, urban pediatric emergency department between 2003 and 2006 were mapped to census block groups using geographical information systems software. Fracture rates were calculated as fractures per 1000 children in each census block. Exploratory factor analysis of socioeconomic indicators was performed using 2000 census block data. Factor scores were used to predict odds of bone fracture at the individual level while adjusting for mean age, sex composition, and race/ethnicity composition at census block level using our sample data.

Results We analyzed 3764 fracture visits in 3557 patients representing 349 distinct census blocks groups. Fracture rates among census blocks ranged from 0 to 207 per 1000 children/study period. Logistic regression modeling identified 2 factors (race/education and large families) associated with increased fracture risk. Census variables reflecting African American race, laborer/service industry employment, long-term block group residence, and lower education levels strongly loaded on the race/education factor. The large families factor indicated the children-to-families ratio within the block group. The poverty factor was not independently associated with fracture risk.

Conclusions Thus, neighborhood characteristics are associated with risk for fractures in children. These results can help inform translational efforts to develop targeted strategies for bone fracture prevention in children.

Key Words
  • injury
  • fracture
  • community methodology

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