To characterize the demographic characteristics of shotgun wounds in children and adolescents across various regions within a state. Retrospective case study. Accredited trauma centers in Pennsylvania. All patients less than 18 years old who sustained shotgun wounds. Patient data were collected from the Pennsylvania Trauma Systems Foundation statewide trauma registry for January 1987 through December 1994. Data reviewed included age, race, sex, region, nature of injury, assailant, location of incident, length of stay in the hospital and intensive care unit, Injury Severity Score, organs injured, death, and discharge disposition. Over 8 years there were 95 shotgun wounds in patients with a mean +/- SD age of 14.0 +/- 3.7 years; the male-to-female ratio was 5.8:1. The incidence of shotgun wounds in urban areas increased threefold during the second half of the study; the incidence in nonurban regions was unchanged. Eighteen deaths (19%) occurred, 17 (94%) within 24 hours and 10 (56%) because of intracranial injury. Overall, unintentional shotgun wounds were most common (n = 46 [48%]), followed by assaults (n = 37 [39%]) and suicides (n = 8 [8%]). The highest per capita incidence of shotgun wounds occurred in urban areas, typically the result of an assault (n = 30 [73%]). In nonurban areas, shotgun wounds were usually unintentional (n = 36 [67%]); 34 (63%) occurred in the home. In contrast, in urban areas, 26 shotgun wounds (63%) occurred on the street. Overall, 14 fatal shotgun wounds (78%) occurred in the home. Operative intervention was required for 57 patients (60%). Ultimately, 67 patients (71%) were discharged to home. In urban areas, shotgun wounds are increasing in incidence, often occur on the street, and often result from assault. In nonurban areas, shotgun wounds are usually unintentional, often occur in the home, and are more often lethal than shotgun wounds in urban areas. Multiple-organ injury, surgery, and lengthy hospital stays are common.