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Background: Practice variation exists in pain management of children with long bone fractures (LBFs)., Objective: The objectives of this study were to describe current pain management in children with LBFs and the factors associated with the undertreatment of pain., Methods: We retrospectively studied children (aged 0-18 years) with a diagnosis of LBF in a pediatric emergency department (PED) from November 2015 through August 2016. Demographic characteristics and quality measures were noted. We determined the impact of PED crowding using the National Emergency Department Overcrowding Scale., Results: A total of 905 patients (63% male, 48% African American) were enrolled. Median age was 6 years (interquartile range [IQR] 7 years), 72% had upper extremity injuries, falls were the most common mechanism (74%), and the majority were discharged (77%). Median time to pain score was 6 min (IQR 14 min). Seventy-two percent received analgesia with a median time to order of 63 min and medication receipt of 87 min. Ibuprofen was the analgesia prescribed most commonly. There were no identified factors associated with oligoanalgesia. Nonuse of narcotics was associated with African-American race, public insurance, single fractures, and arrival via private vehicle. Ambulance arrivals, lower extremity fractures, and disaster mode were associated with receiving analgesia within 60 min., Conclusions: In our study, 28% of children with LBFs did not receive pain medications, especially during normal PED volumes. Additional studies are required to explore triage as a venue for analgesia delivery for LBFs., (Copyright © 2019 Elsevier Inc. All rights reserved.)