Objectives: Pediatric fractures suspicious for abuse are often evaluated in emergency departments (ED), although corresponding diagnostic coding for possible abuse may be lacking. Thus, the primary objective of this study was to determine the proportion of fracture cases investigated in the ED for abuse that had corresponding International Classification of Diseases (ICD) codes documenting abuse suspicion. Additional objectives were to determine the proportion of these fractures with admission ICD abuse coding, and physician text diagnoses recording abuse suspicion in the ED and/or admission notes. Factors possibly associated with abuse-related ED ICD codes were also examined. Methods: Children less than three years of age that presented primarily with a fracture to two large academic children's hospitals from 1997 to 2007 and were evaluated for suspicion of abuse by child protective services were included in this retrospective review. The main outcome measure was the proportion of the fracture cases that had abuse suspicion reflected in ED discharge ICD codes. Results: Of the 216 eligible patients, only 23 (11.5%) patients had ED ICD codes that included the possibility of abuse. Forty-nine (22.7%) had the possibility for abuse documented by physicians as an ED discharge diagnosis. In addition, 53/149 (35.6%) of all admitted patients and 34/55 (61.8%) of confirmed abuse cases included abuse-related admission ICD coding. Female gender was found to be a factor associated with ED ICD abuse codes. Conclusion: Current standards of ICD coding result in a significant underestimate of the prevalence of children assessed in the ED and hospital wards for possible and confirmed abusive fracture(s). (Contains 1 figure and 5 tables.)