Objective The goal of the study was to systematically review available evidence regarding differences in injury incidence between rural and urban paediatric populations in Canada and the USA.

Data source Eight electronic databases, institutional websites and reference lists of relevant studies including published and unpublished reports.

Selection criteria Population-based observational studies or surveys published from 1970 to February 2011 that compared injury incidence or injury-related healthcare outcomes between rural and urban children (<18) living in Canada or the USA.

Data collection and analysis Two reviewers independently applied selection criteria and assessed methodological quality of studies. Data were extracted by one author and independently verified by the second author. Injury rate ratios for rural and urban children were extracted or calculated. Data were synthesised descriptively due to substantial heterogeneity among studies.

Results A total of 41 studies were included for this review (seven surveys and 34 studies using administrative health databases). Internal validity of included studies was moderate. Rural children were at higher risk of overall injury, motor vehicle crash injury and suicide, whereas urban children in the USA experienced higher rates of firearm-related homicides. Greater rural–urban injury disparities were likely to be found between more extreme rural and urban areas. In particular, children in remote rural areas are at increased risk of severe injuries than urban counterparts. Overall, healthcare costs per child for injury were higher for rural children.

Conclusion These findings indicate the need of developing geographic area-specific injury-prevention strategies. Future research is required to investigate rural–urban disparity for less-studied injuries and related health outcomes (eg, disability).

Systematic review registration number CRD42011001244 (PROSPERO 2011).