This report describes the epidemiology of pedestrian injury in four inner metropolitan local government areas of Sydney. These data were obtained from the Roads and Traffic Authority of New South Wales. The spectrum of injury and clinical outcome was defined in patients with an Injury Severity Score (ISS)>15 admitted from the study area, during a 1 year period, to the four inner metropolitan teaching hospitals. The incidence of pedestrian death was 3.3 times the state average of 32/106/year. An average of 235 pedestrians, injured in the study area, were hospitalized each year during the period 1987–89. On average 24 pedestrians died each year, seven at the scene and 17 in hospital.Fifty patients (ISS>15) were admitted to the four teaching hospitals during a 1 year period 1990–91. Forty‐five were adults and five children. Multiplicity of injury was seen in 68% of patients. The pelvis and lower extremities were involved in 70%, the head in 66% and chest in 42%. The hospital mortality rate was 30% with five patients dying on the first day from blood loss and nine dying during subsequent days from head injury.This study has important implications for trauma service development. Successful clinical management of the severely injured pedestrian requires close co‐operation between pre‐hospital and hospital care providers. An integrated hospital trauma team response is mandatory to ensure appropriate management of what is often a shocked, hypoxic. head‐inju