1. Introduction
Pediatric road traffic injuries (RTIs) remain a pressing global concern, with profound implications for child health, public safety, and socioeconomic development. According to the United Nations International Children’s Emergency Fund (UNICEF), in 2022 nearly 181,453 individuals under the age of 20 lost their lives due to road-traffic incidents, with over 90% of these fatalities occurring in low- and middle-income countries [
1]. Romania, initially classified as an upper-middle-income country in 2020 [
2], was later reclassified by the World Bank as a high-income nation in 2021 and 2022 [
3], yet it continues to face persistent challenges in addressing pediatric traffic trauma.
The World Health Organization (WHO) estimates that 20 to 50 million people globally suffer non-fatal injuries annually as a result of road collisions, with many cases resulting in long-term or permanent impairments [
4]. These figures underscore the reality that fatalities represent only a fraction of the total burden, as non-fatal injuries often impose lasting physical, psychological, and socioeconomic consequences. In fact, the economic cost of traffic-related incidents is staggering—estimated at USD 518 billion annually—representing up to 3% of GDP in certain regions due to healthcare costs, loss of productivity, and prolonged disability care [
5].
RTIs are increasingly viewed as emblematic of the so-called “diseases of development,” driven by surging vehicle numbers, population growth, and rapidly transforming urban environments [
6]. By 2025, traffic-related injuries are expected to become the third-leading contributor to global disease burden, while their total impact is projected to rank fourth overall [
7].
One of the primary contributors to high injury rates is inadequate road infrastructure. Romania consistently receives poor evaluations regarding road quality. In 2022, for example, the World Economic Forum rated its infrastructure at just 3.0 out of 7—among the lowest in Europe—highlighting an urgent need for investment and reform [
8]. This infrastructural deficit partially explains the country’s elevated rates of traffic injuries and fatalities among children.
Despite often being labeled as minor, non-fatal injuries can result in severe physical and psychological outcomes that diminish long-term well-being and impose substantial burdens on families and communities [
9,
10]. Children, in particular, are highly vulnerable in traffic environments. Although they may possess sufficient motor coordination to move through public spaces, they frequently lack the cognitive, perceptual, and behavioral maturity necessary to accurately assess traffic risks [
11]. Pedestrian injuries, which are prevalent among children in many countries, frequently lead to more severe trauma than incidents involving child passengers inside vehicles [
12,
13,
14].
The trauma profiles of pediatric patients also differ from those of adults due to anatomical and physiological factors. Lower body mass results in reduced kinetic energy upon impact, and their typical seating position in the rear of vehicles offers added protection. As a result, children generally experience fewer thoracic, abdominal, pelvic, and long bone injuries and often present with lower Injury Severity Scores (ISSs), despite potentially high Glasgow Coma Scale scores [
15,
16]. Moreover, children’s greater biological resilience enhances their capacity to recover without long-term sequelae; however, when permanent outcomes do occur, medico-legal assessment—such as Personal Injury Assessment (PIA)—is complicated by the unpredictability of future developmental needs [
15].
The purpose of this study is to assess age- and gender-specific patterns of associated injuries caused by different mechanisms of non-fatal RTIs in children and adolescents, based on cases presented at the Emergency Department and the Pediatric Orthopedics Department of “St. Mary’s” Emergency Clinical Hospital for Children in Iași, Romania. In alignment with the existing literature, the pediatric population was categorized into four age groups to facilitate comparative analysis of injury trends across developmental stages [
15,
17].
2. Materials and Methods
This retrospective, observational study was conducted over a 10-year period, from 2015 to 2024, at the Emergency Department (ED) and the Pediatric Orthopedics Department of “St. Mary’s” Emergency Clinical Hospital for Children in Iași, Romania.
The hospital serves as a regional referral center for pediatric trauma, providing care to both urban and rural populations across Iași County and the seven surrounding counties of northeastern Romania. The ED receives approximately 40,000 visits annually, with around 4% of these involving trauma cases. Around 54% of those trauma cases affect children between the ages of 7 and 14 years. Between 98 and 127 pediatric RTIs are recorded at the hospital each year, with an average of 102 cases annually.
Patients eligible for inclusion in the study were aged between 1 month and 17 years and 11 months and had sustained injuries resulting from road traffic injuries, with documented presentation to the Emergency Department and subsequent hospitalization in the Pediatric Orthopedics Department. Relevant data were extracted from the hospital’s electronic medical record system, primarily based on ICD-10 external cause codes V01–V99, among which the most frequently identified were V03.1, V06.1, V01.1, V10.3, V10.4, V10.5, V10.9, V13.3, V13.4, V13.5, V13.9, V19.4, V19.5, V19.9, V40.09, V43.03, V47.03, V80.00, V80.09, V80.1, and V99.
To minimize case omission, additional searches were performed using the keywords “road” and “traffic injury.” A manual review was conducted to confirm each case’s relevance, based on the study’s definition of an RTI as a road incident involving at least one moving vehicle. Injuries not related to moving vehicles or to road traffic events were excluded.
A total of 1074 pediatric patients met the inclusion criteria and were included in the analysis. Data collected included demographic information (age and sex), the mechanism and context of the injury, the anatomical region and type of injury, laboratory and imaging investigations, and the treatment approach (conservative or surgical). Injuries were classified based on the child’s role or location at the time of the injury (e.g., pedestrian, cyclist, passenger, and other types of injuries that include a small number of patients who sustained falls from a horse by traffic injury or were in a wagon pulled by horses implicated in a traffic injury), while injuries were classified by anatomical location and nature.
Injury categories were standardized for consistency and included excoriations, defined as superficial skin abrasions not involving deeper tissue; thoracic contusions, referring to chest wall soft tissue injuries (bruising of skin, subcutaneous tissue, and musculature) without confirmed internal organ involvement such as pulmonary or cardiac contusions; abdominal contusions, encompassing both abdominal wall soft tissue injuries and, when applicable, internal organ contusions involving the liver, spleen, or other abdominal viscera; additional fractures, representing bone fractures beyond the primary injury, either multiple fractures within the same limb or simultaneous fractures in different anatomical regions; traumatic brain injuries (TBIs), including documented concussions, intracranial hemorrhage, or skull fractures confirmed by clinical or imaging evaluation; limb contusions, characterized as localized bruising of the extremities without associated fracture; and hematologic alterations, defined as blood count abnormalities, primarily decreases in hemoglobin and hematocrit indicative of blood loss.
Patients were stratified into four age categories: 0–4 years (early childhood), 5–9 years (middle childhood), 10–14 years (early adolescence), and 15–17 years (late adolescence).
Statistical analyses were performed using IBM SPSS Statistics (Version 25) (IBM Corp., Armonk, NY, USA). Descriptive statistics for continuous variables included mean, median, standard deviation, and range (minimum and maximum values). For continuous variables, comparisons were made using Mann–Whitney U test and the Kruskal–Wallis H test. Categorical variables were reported as absolute and relative frequencies, with comparisons made using Fisher’s exact test. A p-value < 0.05 was considered statistically significant.
The study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the Ethics Committees of both “St. Mary’s” Emergency Clinical Hospital for Children and the “Grigore T. Popa” University of Medicine and Pharmacy in Iași. Informed consent was obtained from all legal guardians at the time of admission. Consent forms authorized the use of medical data for research and educational purposes, approved the collection of biological samples and application of necessary diagnostic and therapeutic procedures, and granted permission for photo or video documentation for scientific use, with measures taken to ensure anonymity. All data were fully anonymized, excluding any personal identifiers such as national identification numbers, photos, or diagnostic reports that could lead to patient identification. Data handling complied with EU Regulation 2016/679 (GDPR) to protect patient privacy and confidentiality.
3. Results
3.1. Demographic Characteristics
The average age among all cases was 11.1 ± 4.4 years, with a median of 12 years. The largest proportion of cases fell within the 10–14 year age group (45.5%), followed by those aged 15–17 (23.7%). A clear majority of the patients were male, representing 77.7% of the total. Statistical analysis showed no significant differences between males and females in terms of age, whether treated as a continuous or categorical variable (p > 0.05). Most patients were between 10 and 14 years of age, with 52.1% of females and 45.2% of males falling into this range. For both sexes, the median age remained consistent at 12 years.
Among the cases analyzed, 15 children were under the age of 1 at the time of data collection, comprising 14 boys and 1 girl. Based on the box plot analysis, the distribution of age in the male group extended toward the lower age range (median = 12 years, IQR = 8–14 years). Given that the lower threshold for detecting outliers resulted in no boys under 1 year being flagged as outliers, this age category was not considered statistically significant. In contrast, the single female patient under 1 year of age was classified as an outlier.
3.2. Urban–Rural Distribution
There was a statistically significant difference in the distribution of sex across residential settings (p = 0.005), with a higher proportion of male patients in rural areas compared to females (79.5% vs. 63.7%), and a higher proportion of females in urban areas compared to males (36.3% vs. 20.5%).
3.3. Accident Type by Age
Children aged 0 to 4 years were most commonly involved as car passengers, significantly more than as pedestrians, cyclists, or participants in other types of injuries (28.8% compared to 9.2%, 7%, and 3.4%, respectively). In contrast, adolescents aged 15 to 17 years were more often injured in other types of injuries or while cycling than as pedestrians or vehicle passengers (46.5% and 28.1% versus 22.2% and 8.2%, respectively) (
p < 0.001) (
Figure 1).
Age plays a significant role in determining the type of injury sustained (p < 0.001). For example, the probability of being injured as a car passenger decreases significantly with age. The regression coefficient for this category is −0.129 (p < 0.001), with an Exp (B) value of 0.879, indicating a 12.1% decrease in odds for each additional year of age compared to the reference group—pedestrians. In contrast, the likelihood of being involved in other types of injuries rises with age. This is reflected by a coefficient of 0.53, which is also statistically significant (p < 0.001). The corresponding Exp (B) of 1.703 suggests that with each additional year, the odds of experiencing this type of injury increase by approximately 70.3% relative to pedestrians. However, age does not significantly influence all injury categories.
There was a statistically significant association between age group and injury type (
p < 0.001), indicating that certain injury types were more frequent in specific age categories. On the contrary, gender did not demonstrate a statistically significant association with the type of injury (0.09). This suggests that the distribution of injury types is comparable between males and females in this study (
Table 1).
3.4. Associated Injuries—General Overview
Most of the patients included in our study had associated injuries, with a total of 798 cases (74.3%). The most frequently observed injuries were excoriations in 193 cases (24.1%), thoracic contusions in 130 cases (16.4%), abdominal contusions in 118 cases (14.8%), additional fractures in 86 cases (10.8%), traumatic brain injuries (TBI) in 82 cases (10.2%), limb contusions in 68 cases (8.5%), and hematologic alterations in 62 cases (7.8%). The remaining 7.4% consisted of a diverse range of injuries and conditions, such as spinal injuries, hemoperitoneum, traumatic shock, acute ischemia syndrome, hematoma, ecchymosis, gross hematuria, burns, sprains or dislocations accompanied by localized edema and hemarthrosis.
3.5. Specific Injury Patterns
3.5.1. Traumatic Brain Injury (TBI)
There was no statistically significant association between abdominal contusions and accident type (
p = 0.09), indicating that the mechanism of injury did not substantially influence their occurrence (
Table 2). Similarly, no significant association was observed between abdominal contusions and sex (
p = 0.59), suggesting that gender was not a determining factor. However, a significant association was found with age group (
p = 0.03), with children aged 0–4 years experiencing a higher rate of abdominal contusions than those aged 10–14 years, as confirmed by Dunn–Bonferroni post hoc analysis (
Table 3).
3.5.2. Thoracic Contusions
Thoracic contusion rates did not differ significantly across injury categories (
p = 0.11) (
Table 3). Nevertheless, a statistically significant difference (
p = 0.04) was observed when classified by sex, with females experiencing thoracic contusions at a higher rate than males (31.5% vs. 20%) (
Figure 2 and
Table 4).
There was no statistically significant association between the incidence of thoracic contusions and age group (
p = 0.22) (
Table 5).
3.5.3. Abdominal Contusions
Fisher’s exact test revealed no statistically significant differences in the frequency of abdominal contusions across injury types (
p = 0.59) or between sexes (
p = 0.11), indicating that neither crash mechanism nor gender had a substantial impact on their occurrence. However, a significant age-related variation was identified, with children aged 0–4 years experiencing a higher rate of abdominal contusions compared to those aged 10–14 years. This difference was confirmed by Fisher’s exact test (
p = 0.03) and further validated through Dunn-Bonferroni post hoc analysis (
Table 6 and
Table 7).
3.5.4. Blood Count Abnormalities
Fisher’s exact test (
p = 0.003) revealed a significant association between injury type and the occurrence of blood count changes, with Bonferroni-adjusted Z-tests showing that cyclists were more frequently affected (50% vs. 22.6%). In contrast, there was no statistically significant association with sex (
p = 1.000) (
Table 8 and
Figure 3).
3.5.5. Limb Contusions
There was no statistically significant association between the occurrence of limb contusions and injury mechanism (
p = 0.39), sex (
p = 0.67), or age group (
p = 0.19) (
Figure 4 and
Table 9).
3.5.6. Excoriations
There was no statistically significant association between the occurrence of excoriations and patient sex (
p = 0.68). In contrast, a significant difference was found across age groups (
p < 0.001). Post hoc Dunn–Bonferroni analysis showed that excoriations were significantly less frequent in the youngest children (6.5% vs. 13.8%) and in older adolescents (12.5% vs. 28.3%), whereas children aged 10–14 years had a markedly higher prevalence (57.7% vs. 40.6%) (
Table 10).
Patients injured as cyclists exhibited excoriations at a markedly higher rate than other groups (39.4% versus 18.9%;
p = 0.001) (
Figure 5).
3.6. Protective Measures
Among the 163 pediatric patients identified as car passengers, restraint status was documented in 89.6% of cases: 57.7% were seated unrestrained in the rear seat, 20.9% were held in the caregiver’s arms, and only 11.0% were appropriately secured using an age-appropriate child safety seat; restraint status was unknown in the remaining 10.4% of patients.
Among the 199 pediatric bicycle accident victims, 155 (78%) were not wearing helmets. Regarding accident type, 117 cases (58.8%) resulted from collisions with vehicles, 44 cases (22.1%) from falls on public roads, and 38 cases (19.1%) were unspecified. Helmet use was documented in only 13 vehicle collisions (11.1%), 17 falls (38.6%), and 14 unspecified incidents (36.8%). Both the absolute numbers and compliance rates indicate particularly low helmet use in high-energy crashes such as vehicle collisions. Within this cohort, 11 children (5.5%) sustained traumatic cranio-cerebral (TCC) injuries, with approximately 9 occurring among cyclists without a helmet and 2 among helmeted cyclists. No cases of coma were reported, suggesting that although head trauma was present, progression to severe neurological compromise was not observed (
Figure 6).