Transferrals and clinical pathways of unstable pelvic fractures over the last 10 years - A retrospective analysis of the Trauma Register DGU®

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They correlate with a severity of trauma and the initial medical treatment is decisive. This study evaluated the transferrals of such fractures and described the initial treatment as well as the clinical course. Methods We analysed retrospective data from a large cohort of the TraumaRegister DGU® (TR-DGU), covering the period from 2014 to 2023, comprising a total of n = 397,910 patients. All patients aged ≥ 16 years were included. Injury patterns were described according to the Abbreviated Injury Scale (AIS), the mechanically unstable fractures were classified with an AIS ≥ 3. We considered all participating hospitals within Germany. The patients were subdivided in three groups: Group 1 = primary admitted patients with outcome, group 2 = pre-treated patients transferred in from other hospitals, and group 3 = primary admitted and early (< 48 hours) transferred out. Results The majority of the patients was male and about 53 years old. Blunt trauma was the leading trauma mechanism. Concomitant injuries (AIS 2+) affected thorax (56%), spinal cord (41%), lower extremities (38%), head (31%) and abdomen (24%). Among primary admitted cases with pelvic fractures (n = 36,398), 21,091 cases (57.9%) had an unstable pelvic fracture (AIS pelvis 3–5). Level 1 trauma centers not only treated 12,836 primary admitted cases with unstable pelvic fracture (83.5%) but also received 2,365 patients (15.4%) from other hospitals via transfer; only 1% of cases were transferred out early (n = 170). Transfusion was applied in 5,984 patients (16.5%) (AIS 2–5). A pelvic binder was applied in 7,096 (36.3%) patients and surgical stabilisation was performed in 4,075 (14.9%) patients. The length of stay on intensive care unit was highest in AIS 5 with 6 days. The mortality rate was 38.5% in AIS 5, and 9.9% in AIS 2. Conclusion The prevalence of unstable pelvic ring fractures (AIS 3–5) constantly remained around 9%. Unstable pelvic fractures were increasingly transferred to a Level I trauma center. The unstable pelvic fractures correlated with a high the Injury Severity Score (ISS). The early treatment involved the transfusion of packed red blood cells, the application of a pelvic binder and the surgical stabilisation. Though, these tools were increasingly utilized with the severity of trauma. Pelvic fracture Severe Trauma Transferral TraumaRegister DGU® Level I Trauma center Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Pelvic fractures are classified as mechanically stable or unstable and their initial medical treatment is decisive. Therefore, trauma centers are well-equipped to provide rapid diagnosis and multidisciplinary care ( 1 – 3 ). Pelvic fractures often result from high-energy trauma, such as road traffic accidents or falls from significant heights, but may also occur in the elderly following low-energy trauma ( 4 ). The incidence is currently listed between 20 and 40 per 100,000 patients worldwide ( 5 – 7 ). These injuries pose a high risk for associated haemorrhage, neurovascular injury, soft tissue trauma as these fractures usually occur in severe trauma ( 5 ). The mortality rate increases up to 60% in case of haemodynamic instability ( 8 ). The classification is based on the pattern, mechanic stability, and mechanism of injury. Recent classification systems, such as the Orthopaedic Trauma Association (OTA) classification, offer a detailed framework by categorizing pelvic fractures into types and subtypes that reflect injury complexity and mechanical stability. Tile's classification categorizes fractures into stable (Type A), potentially unstable (Type B), and unstable (Type C) based on stability and injury mechanism ( 9 , 10 ). The Young-Burgess system emphasizes the direction of the impact force, such as lateral compression, anterior-posterior compression, or vertical shear, which helps guide treatment decisions ( 11 ). Accurate classification is crucial for determining management strategies and predicting outcomes. The management of mechanically unstable pelvic fractures has emphasized early stabilization to improve outcomes. Hemodynamic resuscitation through rapid assessment and timely interventions, such as pelvic packing or angioembolization, represents established clinical practice in the management of unstable pelvic fractures. Its effectiveness in controlling haemorrhage and improving outcomes is well supported by recent studies ( 12 , 13 ). For stable pelvic fractures, conservative treatment remains effective, focusing on pain management and mobilization protocols ( 14 ). In contrast, surgical stabilization—particularly through minimally invasive techniques such as percutaneous fixation—has become increasingly favoured for the treatment of unstable fractures, especially in elderly patients. These techniques minimize surgical trauma and are particularly advantageous in this population, as elderly patients often have limited physiological reserves and are frequently unable to comply with partial weight-bearing instructions ( 5 , 15 ). Ultimately, the management of unstable pelvic fractures requires a multidisciplinary approach, emphasizing rapid mechanical stabilization and thorough evaluation of associated injuries to achieve optimal outcomes. This retrospective study was designed to characterize the transferrals and clinical pathways of stable and unstable pelvic fractures among the three levels of trauma centers within the German Trauma Network. The following questions needed to be answered: Which entities were primarily transported in which center? Which fractures were transferred? The characteristics and medical treatment options were analysed. The investigation was based on data from the TraumaRegister DGU®. Methods TraumaRegister DGU® The TraumaRegister DGU ® of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie, DGU) was founded in 1993. The aim of this multi-centre database is a pseudonymised and standardised documentation of severely injured patients. Data are collected prospectively in four consecutive time phases from the site of the accident until dis- charge from hospital: A) Pre-hospital phase, B) Emergency room and initial surgery, C) Intensive care unit and D) Discharge. The documentation includes comprehensive data on patient demographics, injury patterns, comorbidities, prehospital and in-hospital management, intensive care unit course, relevant laboratory findings—including transfusion data—and individual patient outcomes. The inclusion criterion is admission to hospital via emergency room with subsequent ICU/ICM care or reach the hospital with vital signs and die before admission to ICU. The infrastructure for documentation, data management, and data analysis is provided by AUC - Academy for Trauma Surgery (AUC - Akademie der Unfallchirurgie GmbH), a company affiliated to the German Trauma Society. The scientific leadership is provided by the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society. The participating hospitals submit their data pseudonymised into a central database via a web-based application. Scientific data ana- lysis is approved according to a peer review procedure laid down in the publication guideline of TraumaRegister DGU ® . The participating hospitals are primarily located in Germany (90%), but a rising number of hospitals of other countries contribute data as well (at the moment from Austria, Belgium, China, Finland, Luxembourg, Slovenia, Switzerland, The Netherlands, and the United Arab Emirates). Currently, more than 30,000 cases from around 700 hospitals are entered into the database per year. Participation in TraumaRegister DGU ® is voluntary. For hospitals associated with TraumaNetzwerk DGU ® , however, the entry of at least a basic data set is obligatory for reasons of quality assurance. The present study adheres to the publication guidelines of the TraumaRegister DGU ® and is registered under project ID 2024-036. Patient cohort The investigation was based on the standard documentation protocol of the TraumaRegister DGU®. Trauma mechanisms were distinguished by blunt and penetrating injuries. Blunt trauma included falls from heights less than or greater than 3 meters, car accidents, motorcycle or bicycle accidents, pedestrian accidents, and other non-penetrating causes. Resuscitation techniques were chiefly based on current guidelines provided by the “S3-Leitlinie Polytrauma” chiefly based on Advanced Trauma Life Support® (ATLS) ( 16 ). All patients aged ≥ 16 years were included. Eligibility criteria comprised a Maximum Abbreviated Injury Score (MAIS) ≥ 3 and/or the requirement for intensive care unit (ICU) treatment. Injury patterns were described according to the Abbreviated Injury Scale (AIS), the mechanically unstable fractures were classified with an AIS ≥ 3. The Injury Severity Score (ISS) was described as it is commonly used in trauma care. The detailed surgical options were documented in TR-DGU since 2020. We considered all participating hospitals within Germany. A consort diagram displays the detailed numbers due to inclusion and exclusion criteria (Fig. 1). Statistical analysis Data are presented as numbers with percentage for categorical data, and as mean with standard deviation (SD) for metric data. In skewed data, median with quartiles were reported instead of mean/SD. The patients were subdivided in three groups: Group 1 = primary admitted patients with outcome, group 2 = pre-treated patients transferred in from other hospitals, and group 3 = primary admitted and early (< 48 hours) transferred out. Since patients from group 2 and 3 may be entered twice (by different hospitals), analyses based on individual cases only considered either primary admissions only (group 1 and 3), in case of early data, or groups 1 and 2 in case of outcome analysis. All analyses were performed using SPSS statistical software (version 29, IBM Inc., Armonk, NY, U.S.A.) Results Basic data The in- and exclusion criteria are shown below in Fig. 1. We analysed current data from a large cohort of the TraumaRegister DGU® (TR-DGU), covering the period from 2014 to 2023, comprising a total of n = 397,910 patients. 692 hospitals were involved. The majority of the patients with stable and unstable pelvic fractures was male (65%) and on average 53 years old. Blunt trauma was the leading trauma mechanism (99%). Concomitant injuries (AIS 2+) affected thorax (56%), spinal cord (41%), lower extremities (38%), head (31%) and abdomen (24%), with decreasing prevalence. The incidence of pelvic trauma was 3.4 / 100,000 per year in Germany in 2017 (n = 82,800,000 inhabitants). The prevalence of any and unstable pelvic fractures is shown in Fig. 2 . Interhospital-transfers In general, pelvic fractures (AIS 2–5) were submitted to different levels of trauma centers; supra-regional trauma centers (level 1) received 60.3% of primary admissions with pelvic fractures, while level 2 (regional) and 3 (local) hospitals received 31.0% and 8.7%, respectively. The rate of patients transferred out early was higher in level 2 and 3 hospitals: 14.6% and 32.7%. Among primary admitted cases with pelvic fractures (n = 36,398), 21,091 cases (57.9%) had an unstable pelvic fracture (AIS pelvis 3–5). Patients with unstable pelvic fractures were categorized in three groups: Group 1) Primarily admitted patients with outcome: n = 19,185 (81.0%), Group 2) transfer in patients from other hospitals: n = 2,590 (10.9%), and Group 3) primary admitted patients transfer out early (< 48 hours): n = 1,906 (8.0%). In contrast, patients with stable pelvic fractures were less frequently transferred out early (6.6%, 1090 of 16,595). Level 1 trauma centers not only treated 12,836 primary admitted cases with unstable pelvic fracture (83.5%) but also received 2,365 patients (15.4%) from other hospitals via transfer; only 1% of cases were transferred out early (n = 170). Level 2 trauma centers treated 6589 patients with unstable pelvic fracture, with only 2.8% of patients transferred in (n = 187), but 16.1% cases transferred out early (n = 1060). Level 3 hospitals transferred out 39.3% of their unstable patients (676 of 1,721). The preclinical time (in minutes) from accident until admission to the trauma center was evaluated in unstable pelvic fractures (AIS 3–5) among the three different levels. Data was available in 77% of the cases. In Level 1 (n = 9,347) the time was 67.94 min (± 26.56), in Level 2 60.45 min (± 25.59) and in Level 3 56.75 in (± 26.37). Tables 1 and 2 demonstrate the primary and non-primary admissions of unstable pelvic fractures among the three different levels of trauma centers. Table 1 Primary admitted patients. Unstable pelvic fractures (AIS 3–5). Distribution among Level 1–3 trauma centers. Results in total and in percentage (%). In total 21,091 patients. Primary admitted patients (AIS 3–5) Level 1 13,006 61.7% Level 2 6,402 30.4% Level 3 1,683 8.0% Total 21,091 100% Table 2 Non-primary admitted patients. Unstable pelvic fractures (AIS 3–5). Distribution among Level 1–3 trauma centers. Results in total and in percentage (%). In total 2,590 patients. Non-Primary admitted patients (AIS 3–5) Level 1 2,365 91.3% Level 2 187 7.2% Level 3 38 1.5% Total 2,590 100% Table 3 Clinical data of patients with stable versus unstable pelvic fractures. Numbers in total as mean, in percent (%), and standard deviation (SD). Cohort: Primary admitted patients. Data in mean and standard deviation. * Group 1 only § median and quartiles. # including the following interventions: craniectomy, laminectomy, thoracotomy, laparotomy, revascularization, embolization, external stabilization Primarily admitted patients Stable Fx N = 16,595 Unstable Fx N = 23,681 Age (Mean and SD) 53.8 (21.4) 52.8 (21.1) Sex male 10,585 (69.2%) 13,108 (62.2%) Injuries Penetrating 135 (0.9%) 258 (1.3%) Injury Severity Score ISS (Mean and SD) 18.4 (11.2) 28.1 (14.7) Head (AIS 3+) 3,616 (23.6%) 4,369 (20.7%) Thorax (AIS 3+) 7,249 (47.4%) 9,842 (46.7%) Abdomen (AIS 3+) 1,673 (10.9%) 3,783 (17.9%) Trauma mechanism Car Motor bike Bike Pedestrian High Fall (> 3m) Low Fall (< 3m) 4,052 (26.7%) 2,173 (14.3%) 1,376 (9.1%) 1,183 (7.8%) 3,285 (21.7%) 2,394 (15.8%) 3,894 (18.7%) 3,090 (14.8%) 1,326 (6.4%) 2,447 (11.8%) 6,048 (29.1%) 2,514 (12.1%) Prehospital setting Endotracheal intubation 3,086 (20.9%) 5,370 (26,6%) Volume administration 12,408 (83.9%) 16,893 (83,7%) Pelvic binder 2,305 (28.4%) 4,791 (41,9%) Transportation by helicopter 3,386 (22.9%) 4,975 (24,7%) Clinical setting Early transfer out (< 48 hrs.) 1,090 (7.1%) 1,906 (9.0%) Blood transfusion 1,391 (9.1%) 4,593 (21.9%) Emergency Surgery# 3,964 (25.9%) 7,853 (37.2%) Intrahospital death * 1,421 (10.0%) 19,185 (16.2%) Length of hospital stay * § (Mean and SD) 14 ( 8 – 24 ) days 17 ( 9 – 29 ) days Length of intensive care unit * § (Mean and SD) 3 ( 1 – 8 ) days 3 ( 1 – 12 ) days Early medical treatment of primary admissions (AIS 2–5) The early medical treatment of primary admissions (group 1 and 3) was performed before admission to the intensive care unit (ICU); in the preclinical setting, respectively in the emergency room or in the operating theatre. The treatment was defined as 1) transfusion of packed red blood cells (pRBC), 2) application of a pelvic binder and 3) surgical stabilisation of the pelvis. The results are shown in percentage (see Figs. 2 – 4 ). Transfusion (at least one unit of packed red blood cells (pRBC) before ICU admission) was applied in total n = 5,984 patients (AIS 2–5). A total of n = 30,228 patients did not receive a transfusion. A pelvic binder was applied in n = 7,096 patients. A total of n = 12,435 patients did not receive a pelvic binder. Surgical stabilisation was performed in n = 4,075 patients, a total of 23,174 were not stabilised. Clinical course of primary and secondary admissions (AIS 2–5) In primary admitted cases, pelvic fractures received surgical treatment in 61.1% with AIS 5, in 60.3% with AIS 4, 37.5% with AIS 3 and 18.8% with AIS 2. In secondary admissions after transfer, the rates were even higher: 77.5%, 78.3%, 56.4%, and 39.6%, respectively. Patients transferred out early were operated in 7.8% (n = 233) only. The length of stay on intensive care unit (n = 37,280 patients, early transfer out excluded) was highest in AIS 5 with 6 ( 1 – 18 ) days in 3,434 patients. It was 5 ( 2 – 14 ) days in AIS 4, 2 ( 1 – 8 ) days in AIS 3, and 3 ( 1 – 8 ) days in AIS 2. The mortality rate was 38.5% in AIS 5, 13.2% in AIS 4, 9.2% in AIS 3, and 9.9% in AIS 2. In comparison the mortality rate of primary admissions (n = 18,178) and secondary admissions (n = 2,552) in unstable pelvic fractures (AIS 3–5); 2,942 patients died in primary admissions and 245 in secondary admissions. The last 10 years in Level I trauma centers Different trends were observed in the treatment of unstable pelvic fractures (AIS 3–5) in the last 10 years from 2014 until 2023; the rate of primarily admitted patients remained constantly above 80%. Transferrals increased from 13.2% in 2014 up to 17.0% in 2022. The rate dropped to 13.8% in 2023. The early transfers out were about 1.0%. The surgical stabilisation of pelvis fractures before ICU admission was monitored from 2015 until 2023 (2014 was not documented). The rate constantly remained around 25%. The number of all surgical procedures per patient was around 35% in 2014 and 2015. It increases to a number of around 60% from 2016 until 2023. Discussion Basic data This study illustrated the transferrals and clinical pathways of unstable pelvic fractures in the German Trauma Network over the last 10 years from 2014 until 2023. We evaluated data and transferrals among three different levels of German trauma centers (I-III). We included 23,681 patients with unstable pelvic fractures (AIS 3–5). Our cohort reflected the typical characteristics of severely injured patients; male, blunt trauma mechanism and high injury severity score. The prevalence of pelvic trauma was around 16%, whereas the prevalence of unstable pelvic fractures was around 9%. In comparison; the international rates of pelvic fractures were reported from 12 up to 25% ( 4 , 5 ). Data vary due to the heterogeneity of the studies, including all kinds of pelvic fractures. The majority studies report on severely injured patients which were conducted from multiple center analyses. Giannoudis et al. described a cohort of 159,746 trauma patients which included 11,149 with pelvic ring fractures. These fractures were related to other severe injuries ( 17 ). A study of the Japanese Trauma Data Bank reported on pelvic fractures in a period of 15 years from 2004 until 2018, which included 5,348 patients with isolated pelvic fractures. The investigation compared three different time periods of treatment, which revealed an improved survival rate over the years ( 18 ). Booth et al. observed 439 cases of unstable posterior pelvic ring fractures in a period from 2010 until 2020, they highlighted different surgical techniques ( 8 ). Andrich et al. performed a retrospective observation on patients of 60 years and older, a study on lower energy trauma cases. They calculated an incidence rate of 22.4 per 10,000 inhabitants with a first pelvic fracture whereas the rate of inpatients treatment was 16.5 ( 19 ). A rather new study from Sweden provided data of 87,308 fractures, including pelvic and acetabular fractures. The incidence of pelvic fracturs increased up to 73/100,000 patients during a 16-year period. The majority were female ( 20 ). Interhospital-transferrals of AIS 3–5 To our knowledge, there is no study which considered the differences of primarily-, secondarily admitted patients and early transferrals (< 48 hours). The majority (62%) of unstable pelvic fractures (AIS 3–5) was primarily admitted to Level I trauma centers and 91,3% were secondarily transferred to a Level 1 trauma center. In many countries the management of pelvic fractures is organized in specialized trauma centers. Multidisciplinary teams consistof orthopedic trauma surgeons, radiologists, general- and vascular surgeons, and intensive care specialists, they ensure comprehensive care. The distribution of these centers typically depends on population density and infrastructure. Urban areas tend to have multiple trauma centers, while rural regions may have fewer, leading to longer transportation times for patients. Thus, the German Trauma Society (DGU) has established a trauma network of clinics, which is based on a setup of specialized trauma centers (supraregional, regional and local trauma centers) to fill a gap of undersupply. The participating facilities ensure accountability in the network depending on their equipment and structure (21). Concerning pelvic fractures, there are key aspects which characterize the treatment; 1) Rapid stabilization of the pelvis, often through surgical or conservative methods. 2) Management of associated injuries, such as vascular, organ, or spinal injuries. 3) Pain control and early mobilization to prevent complications. 4) Long-term rehabilitation planning. As the medical treatment of pelvic fractures is standardized, there do exist specific differences among the trauma centers from Level I trauma center to Level III trauma center. Our data clearly point out that the majority of pelvic fractures (AIS 2–5) were primarily admitted to supra-regional trauma centers. Considering unstable pelvic fractures (AIS 3–5), these entities were primarily admitted and in fact, 15% were secondarily transferred to a Level I trauma center. The reasons may be manifold, generally a Level I trauma center is a comprehensive, highly specialized facility designated to provide the highest level of trauma care. These centers are equipped with 24/7 availability of a full range of medical specialists, including trauma surgeons, neurosurgeons, orthopedic surgeons, and critical care teams. They provide outstanding care in the treatment of severely injured patients including pelvic trauma ( 1 ). A graduated Level II trauma center still provides comprehensive trauma care but may not have the same extensive resources or research capabilities as a Level I center. They are capable of managing most urgent and severe trauma cases, including complex injuries like pelvic fractures. Essential diagnostic tools and treatment options are available. In the context of pelvic fractures, Level II centers play a critical role in initial stabilization and management, especially in regions where Level I centers are not immediately accessible. They ensure timely treatment and coordinate transfer to higher-level centers when necessary for definitive care ( 22 ). Considering pelvic fractures, Level III centers are important as they can perform early stabilization procedures and provide initial life-saving interventions. They serve as the first point of contact in remote or underserved areas, ensuring that patients receive timely care and are transferred appropriately for definitive treatment at more equipped trauma centers. Level III hospitals transferred out 39.3% of their unstable patients (676 of 1,721). A study from Norway underlined the importance of imaging and early emergency surgery in trauma care at local hospitals. They favored early communication with supra-regional trauma centers ( 23 ). The ATLS® guidelines recommend an early communication with the next level of trauma care ( 24 ). The transferral is a crucial component of trauma care, considering the interaction with pre-clinical settings ( 25 ). The goal is to ensure a safe and efficient transfer of trauma patients from the injury site to the appropriate trauma center. Effective transport protocols are essential to improve outcomes in pelvic fractures and other traumatic injuries, ensuring timely access to definitive care and reducing complications. Different types of transport exist; the ground ambulance is the most common mode, suitable for shorter distances. Equipped with basic life support (BLS) or advanced life support (ALS) capabilities, including immobilization devices for the pelvis and spine. The helicopter EMS (HEMS) is used for rapid transport over longer distances or in difficult terrain. It offers faster access to trauma centers, especially in rural or remote areas. Equipped with advanced monitoring and airway management tools ( 26 ). Another transportation vehicle is a fixed-wing aircraft, utilized for very long-distance transfers, often used for oversea transferrals ( 27 ). The staff has to consider a proper stabilization of the pelvis and spine to prevent further injury, the continuous vital signs monitoring and airway management, a clear communication between emergency services, receiving hospital, and transport crew to prepare for the patient’s arrival and finally a minimal transport time to prevent secondary damage. Early treatment and clinical course Our cohort with unstable pelvic fractures (AIS 3–5) suffered from severe trauma with a mean Injury Severity Score (ISS) of 28.1. The associated injuries were described as thorax, head and abdomen in descending prevalence ( 4 , 17 ). Life threatening hemorrhage, unstable pelvic fractures and concomitant major injuries have to be addressed immediately. Further harm must be avoided. A number of studies describe therapeutical options which are utilized in the preclinical and early clinical settings ( 5 , 28 – 31 ). Concerning our cohort, measurable therapeutical tools were identified; as the transfusion of packed red blood cells (pRBC), the application of a pelvic binder and the surgical stabilisation of the pelvic ring. These options are documented and measurable by the TraumaRegister DGU® (TR-DGU). The higher the AIS score, the more transfusion of pRBC, the higher the application of pelvic binder and the higher the rate of surgical stabilisation. These therapeutical pathways are indicated by the high severity of trauma. Still, the S3 Guideline on Treatment of Polytrauma of the German Trauma Society (DGU) significantly influences the treatment of severely injured patients ( 16 ). The first approach to handle pelvic fractures is determined by the preclinical treatment, especially by applying a mechanical device ( 32 – 34 ). Several studies addressed the methods and effects of external pelvic stabilization, whereas the application was primarily performed in severely injured patients with ISS > 30. Interestingly, compression devices did not reduce mortality or the need for blood transfusion ( 33 ). Reasonably, patients with high ISS are not in danger just by pelvic fractures, more usually by severe head injury or thoracic lesions. Trentzsch et al. lately outlined that the use of pelvic binder just indicated the severity of injuries instead of being applied in unstable pelvic fractures ( 35 ). Furthermore, continuous optimization of treatment protocols is essential to improve patient outcomes. A large knowledge on pelvic fractures is gained from the German pelvic database which is run by the German Pelvic group as a section of the German Trauma Society (DGU) ( 36 ). Gansslen et al. highlighted the epidemiology and classification of pelvic ring fractures, they essentially depicted the associated injuries leading to a mortality of 13.4% due to the extrapelvic trauma. Lately, an update of pelvic packing was published. The study emphasized the relevance of biomechanical stabilization such as pelvic binder, external fixator, and the pelvic C-clamp. Further direct access to the bleeding source was described such as angioembolization or Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) ( 12 ). Considering the last 10 years in treatment of unstable pelvic fractures, the expertise has been concentrated and focussed in Level I trauma centers. The transferrals clearly increased from Level II and III to Level I. Though guidelines exist which strictly recommend the handling of pelvic ring fractures. This study clearly depicted the current transferrals and clinical pathways of unstable pelvic fractures. As data was generated from the TraumaRegister DGU ® , we referred on a precise documentation of the participating trauma centers. Unfortunately, a lack of data has to be assumed. Further, patients from group 2 and 3 may be entered twice (by different hospitals), analyses based on individual cases only considered either primary admissions only (group 1 and 3), in case of early data, or groups 1 and 2 in case of outcome analysis. There is a definitely a huge need for further research concerning the precise treatment of pelvic ring fractures. To gather such data a multi-center analysis among the three different levels of trauma centers would be worthwhile. Conclusion The prevalence of unstable pelvic ring fractures (AIS 3–5) constantly remained around 9%. Male, blunt trauma and high ISS (28.1) were the patients´ characteristics. Transferrals were differentiated in primary, secondary and early outs among three levels of trauma centers (I–III). A trend was observed as unstable pelvic fractures were inclined to be transferred primarily to a Level I trauma center; further in a 10-year period the number of secondary transfers to Level I increased. The early treatment involved the transfusion of packed red blood cells, the application of a pelvic binder and the surgical stabilisation. These measures were increasingly utilized with trauma severity, which was associated with longer ICU stay and higher mortality. Declarations Conflict of interest: The authors declare no conflict of interest. Funding: There was no funding. Author Contribution M.W made the concept, gathered data and wrote the article. R.P. contributed equally. A.S. enabled the working group to undertake the work. S.L. supported the process in pelvis research in order to develop the paper. R.L. made the statistical part of the whole manuscript and work, he gathered and conducted the data. TR DGU is the working group. L.M. corrected the proofs and set up the mindset. 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[Trauma network of the German Association of Trauma Surgery (DGU). Establishment, organization, and quality assurance of a regional trauma network of the DGU]. Unfallchirurg. 2007;110(4):373–9. Oliphant BW, Tignanelli CJ, Napolitano LM, Goulet JA, Hemmila MR. American College of Surgeons Committee on Trauma verification level affects trauma center management of pelvic ring injuries and patient mortality. J Trauma Acute Care Surg. 2019;86(1):1–10. Dehli T, Bagenholm A, Johnsen LH, Osbakk SA, Fredriksen K, Bartnes K. [Seriously injured patients transferred from local hospitals to a university hospital]. Tidsskr Nor Laegeforen. 2010;130(15):1455–7. van Maarseveen OEC, Ham WHW, van de Ven NLM, Saris TFF, Leenen LPH. Effects of the application of a checklist during trauma resuscitations on ATLS adherence, team performance, and patient-related outcomes: a systematic review. Eur J Trauma Emerg Surg. 2020;46(1):65–72. Wilson MH, Habig K, Wright C, Hughes A, Davies G, Imray CH. Pre-hospital emergency medicine. Lancet. 2015;386(10012):2526–34. Taylor C, Jan S, Curtis K, Tzannes A, Li Q, Palmer C, et al. The cost-effectiveness of physician staffed Helicopter Emergency Medical Service (HEMS) transport to a major trauma centre in NSW, Australia. Injury. 2012;43(11):1843–9. Chen X, Qin FJ, Liang Y, Yu DN, Chen Z, Li M. [Experience of transportation of mass severe burn patients for long distance by air ambulance with fixed wing]. Zhonghua Shao Shang Za Zhi. 2018;34(8):529–31. Burkhardt M, Kristen A, Culemann U, Koehler D, Histing T, Holstein JH, et al. Pelvic fracture in multiple trauma: are we still up-to-date with massive fluid resuscitation? Injury. 2014;45(Suppl 3):S70–5. Martinez F, Alegret N, Carol F, Laso MJ, Zancajo J, Garcia E, et al. Pelvic fracture in the patient with multiple injuries: factors and lesions associated with mortality. Emergencias. 2018;30(2):91–7. Pfeifer R, Klingebiel FK, Balogh ZJ, Beeres FJP, Coimbra R, Fang C, et al. Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process and systematic review. J Trauma Acute Care Surg. 2024;97(4):639–50. Scherer J, Coimbra R, Mariani D, Leenen L, Komadina R, Peralta R, et al. Standards of fracture care in polytrauma: results of a Europe-wide survey by the ESTES polytrauma section. Eur J Trauma Emerg Surg. 2024;50(3):671–8. Lustenberger T, Walcher F, Lefering R, Schweigkofler U, Wyen H, Marzi I, et al. The Reliability of the Pre-hospital Physical Examination of the Pelvis: A Retrospective, Multicenter Study. World J Surg. 2016;40(12):3073–9. Berger-Groch J, Rueger JM, Czorlich P, Frosch KH, Lefering R, Hoffmann M, et al. Evaluation of Pelvic Circular Compression Devices in Severely Injured Trauma Patients with Pelvic Fractures. Prehosp Emerg Care. 2022;26(4):547–55. Wohlrath B, Trentzsch H, Hoffmann R, Kremer M, Schmidt-Horlohe K, Schweigkofler U. [Preclinical and clinical treatment of instable pelvic injuries: Results of an online survey]. Unfallchirurg. 2016;119(9):755–62. Trentzsch H, Lefering R, Schweigkofler U, TraumaRegister DGU. Imposter or knight in shining armor? Pelvic circumferential compression devices (PCCD) for severe pelvic injuries in patients with multiple trauma: a trauma-registry analysis. Scand J Trauma Resusc Emerg Med. 2024;32(1):2. Pohlemann T, Gansslen A. The German pelvic database. Arch Orthop Trauma Surg. 2025;145(1):167. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 30 Mar, 2026 Reviews received at journal 30 Mar, 2026 Reviews received at journal 06 Mar, 2026 Reviewers agreed at journal 06 Mar, 2026 Reviewers agreed at journal 05 Mar, 2026 Reviewers invited by journal 08 Feb, 2026 Editor assigned by journal 07 Feb, 2026 Submission checks completed at journal 04 Feb, 2026 First submitted to journal 03 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8774696","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588013677,"identity":"ff202ec2-9ee1-42c7-b354-0306644a2713","order_by":0,"name":"Matthias Weuster","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIie3SvwqCQBzAcY+D2mpuqVc4CYKmHqTFcL7doD/nYksPUBD2CrY4nxzoYtwqtBgOzW021fmHoEGlLei+cJ7K74MKKopM9oMhKg6awspLQywISS0ZUwhIQaBYYbaDejKh+URJgJXdayCjgAdxrLA+4txL5vZy2t0IkhpuNQn17MUuQxTpUD27Ad4xQMA2vFQTWpCZE8FWz3R9TASBwKomiCc5WTuctR/mwcfHRhLlT3lqiOotYJIFdppJou40dFP3kT7sEZ/ikyBe3bcgPovvqcEGHe5d72SxwjZnXpwa1aSE77PiN6AN8x+tvhmWyWSyP+kFJ2Fm0zivyW0AAAAASUVORK5CYII=","orcid":"","institution":"Diako Krankenhaus gGmbH Flensburg","correspondingAuthor":true,"prefix":"","firstName":"Matthias","middleName":"","lastName":"Weuster","suffix":""},{"id":588013678,"identity":"96c6fa4f-d516-4528-8f10-eafa51b3e6bf","order_by":1,"name":"Roman Pfeifer","email":"","orcid":"","institution":"Universitätsspital Zürich","correspondingAuthor":false,"prefix":"","firstName":"Roman","middleName":"","lastName":"Pfeifer","suffix":""},{"id":588013679,"identity":"dda65e18-6c09-4cfc-9406-26c68bb7a7bc","order_by":2,"name":"Andreas Seekamp","email":"","orcid":"","institution":"Universitätsklinikum Schleswig-Holstein","correspondingAuthor":false,"prefix":"","firstName":"Andreas","middleName":"","lastName":"Seekamp","suffix":""},{"id":588013680,"identity":"79935772-c3f1-4ae4-9f27-82ec82ea0747","order_by":3,"name":"Sebastian Lippross","email":"","orcid":"","institution":"Schön Klinik Rendsburg","correspondingAuthor":false,"prefix":"","firstName":"Sebastian","middleName":"","lastName":"Lippross","suffix":""},{"id":588013681,"identity":"c1222682-34e1-4248-99da-15ec6f304e20","order_by":4,"name":"Rolf Lefering","email":"","orcid":"","institution":"University of Witten- Herdecke","correspondingAuthor":false,"prefix":"","firstName":"Rolf","middleName":"","lastName":"Lefering","suffix":""},{"id":588013682,"identity":"dc5d4148-f5f4-479d-805e-787bc601240c","order_by":5,"name":"TraumaRegister DGU","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"TraumaRegister","middleName":"","lastName":"DGU","suffix":""},{"id":588013683,"identity":"9ef8ad48-a11b-4839-9ba9-a643be007fa3","order_by":6,"name":"Leif Menzdorf","email":"","orcid":"","institution":"Diako Krankenhaus gGmbH Flensburg","correspondingAuthor":false,"prefix":"","firstName":"Leif","middleName":"","lastName":"Menzdorf","suffix":""}],"badges":[],"createdAt":"2026-02-03 11:02:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8774696/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8774696/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102620811,"identity":"98d0329d-9402-42b8-b7f8-a38ce8d2473e","added_by":"auto","created_at":"2026-02-13 16:45:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":42682,"visible":true,"origin":"","legend":"\u003cp\u003eIn- and exclusion criteria.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8774696/v1/b3f2a7da3edaed2c8c00bbaa.png"},{"id":102620812,"identity":"48bb555e-80fd-49bf-bbd3-a53aefdd1c34","added_by":"auto","created_at":"2026-02-13 16:45:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":18380,"visible":true,"origin":"","legend":"\u003cp\u003ePrevalence of unstable/any pelvic fractures in the last 10 years in TR-DGU (primary admissions only).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8774696/v1/70610ea3bf4d559040a11412.png"},{"id":102747441,"identity":"cb04d348-0652-4287-ae43-5472f98ee16d","added_by":"auto","created_at":"2026-02-16 09:04:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":18754,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2: \u003c/strong\u003eBlood transfusion (at least one unit of packed red cells (pRBC) before ICU admission) in percentage. Early treatment before ICU admission: Preclinical setting, respectively emergency room or operating theatre. X-axis: Pelvic fractures in AIS 2-5 (in ascending order from left). Y-axis: Percentage (%).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8774696/v1/bf6809e63f452e02d42d1e35.png"},{"id":102620815,"identity":"377aaafe-6b6f-46f3-a893-947211a82311","added_by":"auto","created_at":"2026-02-13 16:45:53","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":13964,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 3:\u003c/strong\u003e Application of pelvic binder in percentage. Early treatment before ICU admission: Preclinical setting, respectively emergency room or operating theatre. X-axis: Pelvic fractures in AIS 2-5 (in ascending order from left). Y-axis: Percentage (%).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8774696/v1/3a689deb9e81ce34ad3ec5de.png"},{"id":102747689,"identity":"0a6edc41-3fd8-4a72-97b5-5cb3bf4ae2a4","added_by":"auto","created_at":"2026-02-16 09:05:13","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":18572,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 4: \u003c/strong\u003eSurgical stabilisation of the pelvis in percentage (%). Early treatment before ICU admission:Preclinical setting, respectively emergency room or operating theatre. X-axis: Pelvic fractures in AIS 2-5 (in ascending order from left). Y-axis: Percentage (%).\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8774696/v1/8166bd82bdb1603591e8d59d.png"},{"id":102750850,"identity":"8976e4b1-b706-409a-8acf-484bd12bae92","added_by":"auto","created_at":"2026-02-16 09:22:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":877176,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8774696/v1/5ad99c53-3235-43a2-ab1b-d726fa4e2d2f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eTransferrals and clinical pathways of unstable pelvic fractures over the last 10 years - A retrospective analysis of the Trauma Register DGU\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e®\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePelvic fractures are classified as mechanically stable or unstable and their initial medical treatment is decisive. Therefore, trauma centers are well-equipped to provide rapid diagnosis and multidisciplinary care (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Pelvic fractures often result from high-energy trauma, such as road traffic accidents or falls from significant heights, but may also occur in the elderly following low-energy trauma (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The incidence is currently listed between 20 and 40 per 100,000 patients worldwide (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These injuries pose a high risk for associated haemorrhage, neurovascular injury, soft tissue trauma as these fractures usually occur in severe trauma (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The mortality rate increases up to 60% in case of haemodynamic instability (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The classification is based on the pattern, mechanic stability, and mechanism of injury. Recent classification systems, such as the Orthopaedic Trauma Association (OTA) classification, offer a detailed framework by categorizing pelvic fractures into types and subtypes that reflect injury complexity and mechanical stability. Tile's classification categorizes fractures into stable (Type A), potentially unstable (Type B), and unstable (Type C) based on stability and injury mechanism (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The Young-Burgess system emphasizes the direction of the impact force, such as lateral compression, anterior-posterior compression, or vertical shear, which helps guide treatment decisions (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Accurate classification is crucial for determining management strategies and predicting outcomes. The management of mechanically unstable pelvic fractures has emphasized early stabilization to improve outcomes. Hemodynamic resuscitation through rapid assessment and timely interventions, such as pelvic packing or angioembolization, represents established clinical practice in the management of unstable pelvic fractures. Its effectiveness in controlling haemorrhage and improving outcomes is well supported by recent studies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). For stable pelvic fractures, conservative treatment remains effective, focusing on pain management and mobilization protocols (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In contrast, surgical stabilization\u0026mdash;particularly through minimally invasive techniques such as percutaneous fixation\u0026mdash;has become increasingly favoured for the treatment of unstable fractures, especially in elderly patients. These techniques minimize surgical trauma and are particularly advantageous in this population, as elderly patients often have limited physiological reserves and are frequently unable to comply with partial weight-bearing instructions (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Ultimately, the management of unstable pelvic fractures requires a multidisciplinary approach, emphasizing rapid mechanical stabilization and thorough evaluation of associated injuries to achieve optimal outcomes.\u003c/p\u003e \u003cp\u003eThis retrospective study was designed to characterize the transferrals and clinical pathways of stable and unstable pelvic fractures among the three levels of trauma centers within the German Trauma Network. The following questions needed to be answered: Which entities were primarily transported in which center? Which fractures were transferred? The characteristics and medical treatment options were analysed. The investigation was based on data from the TraumaRegister DGU\u0026reg;.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTraumaRegister DGU\u0026reg;\u003c/h2\u003e \u003cp\u003eThe TraumaRegister DGU\u003csup\u003e\u0026reg;\u003c/sup\u003e of the German Trauma Society (Deutsche Gesellschaft f\u0026uuml;r Unfallchirurgie, DGU) was founded in 1993. The aim of this multi-centre database is a pseudonymised and standardised documentation of severely injured patients. Data are collected prospectively in four consecutive time phases from the site of the accident until dis- charge from hospital: A) Pre-hospital phase, B) Emergency room and initial surgery, C) Intensive care unit and D) Discharge. The documentation includes comprehensive data on patient demographics, injury patterns, comorbidities, prehospital and in-hospital management, intensive care unit course, relevant laboratory findings\u0026mdash;including transfusion data\u0026mdash;and individual patient outcomes. The inclusion criterion is admission to hospital via emergency room with subsequent ICU/ICM care or reach the hospital with vital signs and die before admission to ICU. The infrastructure for documentation, data management, and data analysis is provided by AUC - Academy for Trauma Surgery (AUC - Akademie der Unfallchirurgie GmbH), a company affiliated to the German Trauma Society. The scientific leadership is provided by the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society. The participating hospitals submit their data pseudonymised into a central database via a web-based application. Scientific data ana- lysis is approved according to a peer review procedure laid down in the publication guideline of TraumaRegister DGU\u003csup\u003e\u0026reg;\u003c/sup\u003e. The participating hospitals are primarily located in Germany (90%), but a rising number of hospitals of other countries contribute data as well (at the moment from Austria, Belgium, China, Finland, Luxembourg, Slovenia, Switzerland, The Netherlands, and the United Arab Emirates). Currently, more than 30,000 cases from around 700 hospitals are entered into the database per year. Participation in TraumaRegister DGU\u003csup\u003e\u0026reg;\u003c/sup\u003e is voluntary. For hospitals associated with TraumaNetzwerk DGU\u003csup\u003e\u0026reg;\u003c/sup\u003e, however, the entry of at least a basic data set is obligatory for reasons of quality assurance.\u003c/p\u003e \u003cp\u003eThe present study adheres to the publication guidelines of the TraumaRegister DGU\u003csup\u003e\u0026reg;\u003c/sup\u003e and is registered under project ID 2024-036.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePatient cohort\u003c/h3\u003e\n\u003cp\u003eThe investigation was based on the standard documentation protocol of the TraumaRegister DGU\u0026reg;. Trauma mechanisms were distinguished by blunt and penetrating injuries. Blunt trauma included falls from heights less than or greater than 3 meters, car accidents, motorcycle or bicycle accidents, pedestrian accidents, and other non-penetrating causes. Resuscitation techniques were chiefly based on current guidelines provided by the \u0026ldquo;S3-Leitlinie Polytrauma\u0026rdquo; chiefly based on Advanced Trauma Life Support\u0026reg; (ATLS) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). All patients aged\u0026thinsp;\u0026ge;\u0026thinsp;16 years were included. Eligibility criteria comprised a Maximum Abbreviated Injury Score (MAIS)\u0026thinsp;\u0026ge;\u0026thinsp;3 and/or the requirement for intensive care unit (ICU) treatment. Injury patterns were described according to the Abbreviated Injury Scale (AIS), the mechanically unstable fractures were classified with an AIS\u0026thinsp;\u0026ge;\u0026thinsp;3. The Injury Severity Score (ISS) was described as it is commonly used in trauma care. The detailed surgical options were documented in TR-DGU since 2020. We considered all participating hospitals within Germany. A consort diagram displays the detailed numbers due to inclusion and exclusion criteria (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData are presented as numbers with percentage for categorical data, and as mean with standard deviation (SD) for metric data. In skewed data, median with quartiles were reported instead of mean/SD. The patients were subdivided in three groups: Group 1\u0026thinsp;=\u0026thinsp;primary admitted patients with outcome, group 2\u0026thinsp;=\u0026thinsp;pre-treated patients transferred in from other hospitals, and group 3\u0026thinsp;=\u0026thinsp;primary admitted and early (\u0026lt;\u0026thinsp;48 hours) transferred out. Since patients from group 2 and 3 may be entered twice (by different hospitals), analyses based on individual cases only considered either primary admissions only (group 1 and 3), in case of early data, or groups 1 and 2 in case of outcome analysis.\u003c/p\u003e \u003cp\u003eAll analyses were performed using SPSS statistical software (version 29, IBM Inc., Armonk, NY, U.S.A.)\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eBasic data\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eThe in- and exclusion criteria are shown below in Fig.\u0026nbsp;1.\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003cp\u003eWe analysed current data from a large cohort of the TraumaRegister DGU\u0026reg; (TR-DGU), covering the period from 2014 to 2023, comprising a total of n\u0026thinsp;=\u0026thinsp;397,910 patients. 692 hospitals were involved.\u003c/p\u003e\n \u003cp\u003eThe majority of the patients with stable and unstable pelvic fractures was male (65%) and on average 53 years old. Blunt trauma was the leading trauma mechanism (99%). Concomitant injuries (AIS 2+) affected thorax (56%), spinal cord (41%), lower extremities (38%), head (31%) and abdomen (24%), with decreasing prevalence.\u003c/p\u003e\n \u003cp\u003eThe incidence of pelvic trauma was 3.4 / 100,000 per year in Germany in 2017 (n\u0026thinsp;=\u0026thinsp;82,800,000 inhabitants). The prevalence of any and unstable pelvic fractures is shown in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eInterhospital-transfers\u003c/h3\u003e\n\u003cp\u003eIn general, pelvic fractures (AIS 2\u0026ndash;5) were submitted to different levels of trauma centers; supra-regional trauma centers (level 1) received 60.3% of primary admissions with pelvic fractures, while level 2 (regional) and 3 (local) hospitals received 31.0% and 8.7%, respectively. The rate of patients transferred out early was higher in level 2 and 3 hospitals: 14.6% and 32.7%. Among primary admitted cases with pelvic fractures (n\u0026thinsp;=\u0026thinsp;36,398), 21,091 cases (57.9%) had an unstable pelvic fracture (AIS pelvis 3\u0026ndash;5).\u003c/p\u003e\n\u003cp\u003ePatients with unstable pelvic fractures were categorized in three groups: \u003cstrong\u003eGroup 1)\u003c/strong\u003e Primarily admitted patients with outcome: n\u0026thinsp;=\u0026thinsp;19,185 (81.0%), \u003cstrong\u003eGroup 2)\u003c/strong\u003e transfer in patients from other hospitals: n\u0026thinsp;=\u0026thinsp;2,590 (10.9%), and \u003cstrong\u003eGroup 3)\u003c/strong\u003e primary admitted patients transfer out early (\u0026lt;\u0026thinsp;48 hours): n\u0026thinsp;=\u0026thinsp;1,906 (8.0%). In contrast, patients with stable pelvic fractures were less frequently transferred out early (6.6%, 1090 of 16,595).\u003c/p\u003e\n\u003cp\u003eLevel 1 trauma centers not only treated 12,836 primary admitted cases with unstable pelvic fracture (83.5%) but also received 2,365 patients (15.4%) from other hospitals via transfer; only 1% of cases were transferred out early (n\u0026thinsp;=\u0026thinsp;170). Level 2 trauma centers treated 6589 patients with unstable pelvic fracture, with only 2.8% of patients transferred in (n\u0026thinsp;=\u0026thinsp;187), but 16.1% cases transferred out early (n\u0026thinsp;=\u0026thinsp;1060). Level 3 hospitals transferred out 39.3% of their unstable patients (676 of 1,721).\u003c/p\u003e\n\u003cp\u003eThe preclinical time (in minutes) from accident until admission to the trauma center was evaluated in unstable pelvic fractures (AIS 3\u0026ndash;5) among the three different levels. Data was available in 77% of the cases. In Level 1 (n\u0026thinsp;=\u0026thinsp;9,347) the time was 67.94 min (\u0026plusmn; 26.56), in Level 2 60.45 min (\u0026plusmn; 25.59) and in Level 3 56.75 in (\u0026plusmn; 26.37).\u003c/p\u003e\n\u003cp\u003eTables \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrate the primary and non-primary admissions of unstable pelvic fractures among the three different levels of trauma centers.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePrimary admitted patients. Unstable pelvic fractures (AIS 3\u0026ndash;5). Distribution among Level 1\u0026ndash;3 trauma centers. Results in total and in percentage (%). In total 21,091 patients.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003ePrimary admitted patients (AIS 3\u0026ndash;5)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLevel 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13,006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLevel 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6,402\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLevel 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1,683\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21,091\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003cbr\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eNon-primary admitted patients. Unstable pelvic fractures (AIS 3\u0026ndash;5). Distribution among Level 1\u0026ndash;3 trauma centers. Results in total and in percentage (%). In total 2,590 patients.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003eNon-Primary admitted patients (AIS 3\u0026ndash;5)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLevel 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2,365\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e91.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLevel 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e187\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLevel 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2,590\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eClinical data of patients with stable versus unstable pelvic fractures. Numbers in total as mean, in percent (%), and standard deviation (SD). Cohort: Primary admitted patients. Data in mean and standard deviation. * Group 1 only \u0026sect; median and quartiles. # including the following interventions: craniectomy, laminectomy, thoracotomy, laparotomy, revascularization, embolization, external stabilization\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePrimarily admitted patients\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStable Fx\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;16,595\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eUnstable Fx\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;23,681\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (Mean and SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.8 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.8 (21.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10,585 (69.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13,108 (62.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInjuries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePenetrating\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e135 (0.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e258 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInjury Severity Score ISS (Mean and SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.4 (11.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.1 (14.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHead (AIS 3+)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,616 (23.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,369 (20.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThorax (AIS 3+)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,249 (47.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9,842 (46.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbdomen (AIS 3+)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,673 (10.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,783 (17.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTrauma mechanism\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eCar\u003c/p\u003e\n \u003cp\u003eMotor bike\u003c/p\u003e\n \u003cp\u003eBike\u003c/p\u003e\n \u003cp\u003ePedestrian\u003c/p\u003e\n \u003cp\u003eHigh Fall (\u0026gt;\u0026thinsp;3m)\u003c/p\u003e\n \u003cp\u003eLow Fall (\u0026lt;\u0026thinsp;3m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,052 (26.7%)\u003c/p\u003e\n \u003cp\u003e2,173 (14.3%)\u003c/p\u003e\n \u003cp\u003e1,376 (9.1%)\u003c/p\u003e\n \u003cp\u003e1,183 (7.8%)\u003c/p\u003e\n \u003cp\u003e3,285 (21.7%)\u003c/p\u003e\n \u003cp\u003e2,394 (15.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,894 (18.7%)\u003c/p\u003e\n \u003cp\u003e3,090 (14.8%)\u003c/p\u003e\n \u003cp\u003e1,326 (6.4%)\u003c/p\u003e\n \u003cp\u003e2,447 (11.8%)\u003c/p\u003e\n \u003cp\u003e6,048 (29.1%)\u003c/p\u003e\n \u003cp\u003e2,514 (12.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrehospital setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEndotracheal intubation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,086 (20.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5,370 (26,6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVolume administration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12,408 (83.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16,893 (83,7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePelvic binder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2,305 (28.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,791 (41,9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransportation by helicopter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,386 (22.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,975 (24,7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinical setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEarly transfer out (\u0026lt;\u0026thinsp;48 hrs.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,090 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,906 (9.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlood transfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,391 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4,593 (21.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmergency Surgery#\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,964 (25.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7,853 (37.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntrahospital death *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,421 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19,185 (16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLength of hospital stay * \u0026sect; (Mean and SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e) days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e) days\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLength of intensive care unit * \u0026sect; (Mean and SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e) days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e) days\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3\u003eEarly medical treatment of primary admissions (AIS 2\u0026ndash;5)\u003c/h3\u003e\n\u003cp\u003eThe early medical treatment of primary admissions (group 1 and 3) was performed before admission to the intensive care unit (ICU); in the preclinical setting, respectively in the emergency room or in the operating theatre. The treatment was defined as 1) transfusion of packed red blood cells (pRBC), 2) application of a pelvic binder and 3) surgical stabilisation of the pelvis. The results are shown in percentage (see Figs. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). Transfusion (at least one unit of packed red blood cells (pRBC) before ICU admission) was applied in total n\u0026thinsp;=\u0026thinsp;5,984 patients (AIS 2\u0026ndash;5). A total of n\u0026thinsp;=\u0026thinsp;30,228 patients did not receive a transfusion. A pelvic binder was applied in n\u0026thinsp;=\u0026thinsp;7,096 patients. A total of n\u0026thinsp;=\u0026thinsp;12,435 patients did not receive a pelvic binder. Surgical stabilisation was performed in n\u0026thinsp;=\u0026thinsp;4,075 patients, a total of 23,174 were not stabilised.\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eClinical course of primary and secondary admissions (AIS 2\u0026ndash;5)\u003c/h2\u003e\n \u003cp\u003eIn primary admitted cases, pelvic fractures received surgical treatment in 61.1% with AIS 5, in 60.3% with AIS 4, 37.5% with AIS 3 and 18.8% with AIS 2. In secondary admissions after transfer, the rates were even higher: 77.5%, 78.3%, 56.4%, and 39.6%, respectively. Patients transferred out early were operated in 7.8% (n\u0026thinsp;=\u0026thinsp;233) only. The length of stay on intensive care unit (n\u0026thinsp;=\u0026thinsp;37,280 patients, early transfer out excluded) was highest in AIS 5 with 6 (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e) days in 3,434 patients. It was 5 (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e) days in AIS 4, 2 (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e) days in AIS 3, and 3 (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e) days in AIS 2. The mortality rate was 38.5% in AIS 5, 13.2% in AIS 4, 9.2% in AIS 3, and 9.9% in AIS 2. In comparison the mortality rate of primary admissions (n\u0026thinsp;=\u0026thinsp;18,178) and secondary admissions (n\u0026thinsp;=\u0026thinsp;2,552) in unstable pelvic fractures (AIS 3\u0026ndash;5); 2,942 patients died in primary admissions and 245 in secondary admissions.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eThe last 10 years in Level I trauma centers\u003c/h2\u003e\n \u003cp\u003eDifferent trends were observed in the treatment of unstable pelvic fractures (AIS 3\u0026ndash;5) in the last 10 years from 2014 until 2023; the rate of primarily admitted patients remained constantly above 80%. Transferrals increased from 13.2% in 2014 up to 17.0% in 2022. The rate dropped to 13.8% in 2023. The early transfers out were about 1.0%. The surgical stabilisation of pelvis fractures before ICU admission was monitored from 2015 until 2023 (2014 was not documented). The rate constantly remained around 25%. The number of all surgical procedures per patient was around 35% in 2014 and 2015. It increases to a number of around 60% from 2016 until 2023.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eBasic data\u003c/h2\u003e \u003cp\u003eThis study illustrated the transferrals and clinical pathways of unstable pelvic fractures in the German Trauma Network over the last 10 years from 2014 until 2023. We evaluated data and transferrals among three different levels of German trauma centers (I-III). We included 23,681 patients with unstable pelvic fractures (AIS 3\u0026ndash;5). Our cohort reflected the typical characteristics of severely injured patients; male, blunt trauma mechanism and high injury severity score. The prevalence of pelvic trauma was around 16%, whereas the prevalence of unstable pelvic fractures was around 9%. In comparison; the international rates of pelvic fractures were reported from 12 up to 25% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Data vary due to the heterogeneity of the studies, including all kinds of pelvic fractures. The majority studies report on severely injured patients which were conducted from multiple center analyses. Giannoudis et al. described a cohort of 159,746 trauma patients which included 11,149 with pelvic ring fractures. These fractures were related to other severe injuries (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). A study of the Japanese Trauma Data Bank reported on pelvic fractures in a period of 15 years from 2004 until 2018, which included 5,348 patients with isolated pelvic fractures. The investigation compared three different time periods of treatment, which revealed an improved survival rate over the years (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Booth et al. observed 439 cases of unstable posterior pelvic ring fractures in a period from 2010 until 2020, they highlighted different surgical techniques (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Andrich et al. performed a retrospective observation on patients of 60 years and older, a study on lower energy trauma cases. They calculated an incidence rate of 22.4 per 10,000 inhabitants with a first pelvic fracture whereas the rate of inpatients treatment was 16.5 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). A rather new study from Sweden provided data of 87,308 fractures, including pelvic and acetabular fractures. The incidence of pelvic fracturs increased up to 73/100,000 patients during a 16-year period. The majority were female (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eInterhospital-transferrals of AIS 3\u0026ndash;5\u003c/h2\u003e \u003cp\u003eTo our knowledge, there is no study which considered the differences of primarily-, secondarily admitted patients and early transferrals (\u0026lt;\u0026thinsp;48 hours). The majority (62%) of unstable pelvic fractures (AIS 3\u0026ndash;5) was primarily admitted to Level I trauma centers and 91,3% were secondarily transferred to a Level 1 trauma center.\u003c/p\u003e \u003cp\u003eIn many countries the management of pelvic fractures is organized in specialized trauma centers. Multidisciplinary teams consistof orthopedic trauma surgeons, radiologists, general- and vascular surgeons, and intensive care specialists, they ensure comprehensive care. The distribution of these centers typically depends on population density and infrastructure. Urban areas tend to have multiple trauma centers, while rural regions may have fewer, leading to longer transportation times for patients. Thus, the German Trauma Society (DGU) has established a trauma network of clinics, which is based on a setup of specialized trauma centers (supraregional, regional and local trauma centers) to fill a gap of undersupply. The participating facilities ensure accountability in the network depending on their equipment and structure (21). Concerning pelvic fractures, there are key aspects which characterize the treatment; 1) Rapid stabilization of the pelvis, often through surgical or conservative methods. 2) Management of associated injuries, such as vascular, organ, or spinal injuries. 3) Pain control and early mobilization to prevent complications. 4) Long-term rehabilitation planning.\u003c/p\u003e \u003cp\u003eAs the medical treatment of pelvic fractures is standardized, there do exist specific differences among the trauma centers from Level I trauma center to Level III trauma center. Our data clearly point out that the majority of pelvic fractures (AIS 2\u0026ndash;5) were primarily admitted to supra-regional trauma centers. Considering unstable pelvic fractures (AIS 3\u0026ndash;5), these entities were primarily admitted and in fact, 15% were secondarily transferred to a Level I trauma center. The reasons may be manifold, generally a Level I trauma center is a comprehensive, highly specialized facility designated to provide the highest level of trauma care. These centers are equipped with 24/7 availability of a full range of medical specialists, including trauma surgeons, neurosurgeons, orthopedic surgeons, and critical care teams. They provide outstanding care in the treatment of severely injured patients including pelvic trauma (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). A graduated Level II trauma center still provides comprehensive trauma care but may not have the same extensive resources or research capabilities as a Level I center. They are capable of managing most urgent and severe trauma cases, including complex injuries like pelvic fractures. Essential diagnostic tools and treatment options are available. In the context of pelvic fractures, Level II centers play a critical role in initial stabilization and management, especially in regions where Level I centers are not immediately accessible. They ensure timely treatment and coordinate transfer to higher-level centers when necessary for definitive care (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Considering pelvic fractures, Level III centers are important as they can perform early stabilization procedures and provide initial life-saving interventions. They serve as the first point of contact in remote or underserved areas, ensuring that patients receive timely care and are transferred appropriately for definitive treatment at more equipped trauma centers. Level III hospitals transferred out 39.3% of their unstable patients (676 of 1,721). A study from Norway underlined the importance of imaging and early emergency surgery in trauma care at local hospitals. They favored early communication with supra-regional trauma centers (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The ATLS\u0026reg; guidelines recommend an early communication with the next level of trauma care (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The transferral is a crucial component of trauma care, considering the interaction with pre-clinical settings (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The goal is to ensure a safe and efficient transfer of trauma patients from the injury site to the appropriate trauma center. Effective transport protocols are essential to improve outcomes in pelvic fractures and other traumatic injuries, ensuring timely access to definitive care and reducing complications. Different types of transport exist; the ground ambulance is the most common mode, suitable for shorter distances. Equipped with basic life support (BLS) or advanced life support (ALS) capabilities, including immobilization devices for the pelvis and spine. The helicopter EMS (HEMS) is used for rapid transport over longer distances or in difficult terrain. It offers faster access to trauma centers, especially in rural or remote areas. Equipped with advanced monitoring and airway management tools (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Another transportation vehicle is a fixed-wing aircraft, utilized for very long-distance transfers, often used for oversea transferrals (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The staff has to consider a proper stabilization of the pelvis and spine to prevent further injury, the continuous vital signs monitoring and airway management, a clear communication between emergency services, receiving hospital, and transport crew to prepare for the patient\u0026rsquo;s arrival and finally a minimal transport time to prevent secondary damage.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eEarly treatment and clinical course\u003c/h2\u003e \u003cp\u003eOur cohort with unstable pelvic fractures (AIS 3\u0026ndash;5) suffered from severe trauma with a mean Injury Severity Score (ISS) of 28.1. The associated injuries were described as thorax, head and abdomen in descending prevalence (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Life threatening hemorrhage, unstable pelvic fractures and concomitant major injuries have to be addressed immediately. Further harm must be avoided. A number of studies describe therapeutical options which are utilized in the preclinical and early clinical settings (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29 CR30\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Concerning our cohort, measurable therapeutical tools were identified; as the transfusion of packed red blood cells (pRBC), the application of a pelvic binder and the surgical stabilisation of the pelvic ring. These options are documented and measurable by the TraumaRegister DGU\u0026reg; (TR-DGU). The higher the AIS score, the more transfusion of pRBC, the higher the application of pelvic binder and the higher the rate of surgical stabilisation. These therapeutical pathways are indicated by the high severity of trauma. Still, the S3 Guideline on Treatment of Polytrauma of the German Trauma Society (DGU) significantly influences the treatment of severely injured patients (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The first approach to handle pelvic fractures is determined by the preclinical treatment, especially by applying a mechanical device (\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Several studies addressed the methods and effects of external pelvic stabilization, whereas the application was primarily performed in severely injured patients with ISS\u0026thinsp;\u0026gt;\u0026thinsp;30. Interestingly, compression devices did not reduce mortality or the need for blood transfusion (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Reasonably, patients with high ISS are not in danger just by pelvic fractures, more usually by severe head injury or thoracic lesions. Trentzsch et al. lately outlined that the use of pelvic binder just indicated the severity of injuries instead of being applied in unstable pelvic fractures (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Furthermore, continuous optimization of treatment protocols is essential to improve patient outcomes. A large knowledge on pelvic fractures is gained from the German pelvic database which is run by the German Pelvic group as a section of the German Trauma Society (DGU) (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Gansslen et al. highlighted the epidemiology and classification of pelvic ring fractures, they essentially depicted the associated injuries leading to a mortality of 13.4% due to the extrapelvic trauma. Lately, an update of pelvic packing was published. The study emphasized the relevance of biomechanical stabilization such as pelvic binder, external fixator, and the pelvic C-clamp. Further direct access to the bleeding source was described such as angioembolization or Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Considering the last 10 years in treatment of unstable pelvic fractures, the expertise has been concentrated and focussed in Level I trauma centers. The transferrals clearly increased from Level II and III to Level I. Though guidelines exist which strictly recommend the handling of pelvic ring fractures.\u003c/p\u003e \u003cp\u003eThis study clearly depicted the current transferrals and clinical pathways of unstable pelvic fractures. As data was generated from the TraumaRegister DGU\u003csup\u003e\u0026reg;\u003c/sup\u003e, we referred on a precise documentation of the participating trauma centers. Unfortunately, a lack of data has to be assumed. Further, patients from group 2 and 3 may be entered twice (by different hospitals), analyses based on individual cases only considered either primary admissions only (group 1 and 3), in case of early data, or groups 1 and 2 in case of outcome analysis.\u003c/p\u003e \u003cp\u003eThere is a definitely a huge need for further research concerning the precise treatment of pelvic ring fractures. To gather such data a multi-center analysis among the three different levels of trauma centers would be worthwhile.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe prevalence of unstable pelvic ring fractures (AIS 3\u0026ndash;5) constantly remained around 9%. Male, blunt trauma and high ISS (28.1) were the patients\u0026acute; characteristics. Transferrals were differentiated in primary, secondary and early outs among three levels of trauma centers (I\u0026ndash;III). A trend was observed as unstable pelvic fractures were inclined to be transferred primarily to a Level I trauma center; further in a 10-year period the number of secondary transfers to Level I increased. The early treatment involved the transfusion of packed red blood cells, the application of a pelvic binder and the surgical stabilisation. These measures were increasingly utilized with trauma severity, which was associated with longer ICU stay and higher mortality.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of interest:\u003c/h2\u003e \u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThere was no funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eM.W made the concept, gathered data and wrote the article. R.P. contributed equally. A.S. enabled the working group to undertake the work. S.L. supported the process in pelvis research in order to develop the paper. R.L. made the statistical part of the whole manuscript and work, he gathered and conducted the data. TR DGU is the working group. L.M. corrected the proofs and set up the mindset.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKetter V, Ruchholtz S, Frink M. [Trauma center management]. Med Klin Intensivmed Notfmed. 2021;116(5):400\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaegele M, Gauss T, Cesareo E, Osten P, Ahnert T. [Intrahospital trauma flowcharts: Cognitive support for optimization and acceleration of resuscitation room management of patients with severe injuries and polytrauma]. Unfallchirurgie (Heidelb). 2023;126(7):525\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchoeneberg C, Schilling M, Keitel J, Kauther MD, Burggraf M, Hussmann B, et al. 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Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma. 2001;15(7):468\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrotz MR, Allami MK, Harwood P, Pape HC, Krettek C, Giannoudis PV. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury. 2005;36(1):1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBooth J, Gabbe PB, Neeman T, Perriman DM, Smith PN. Outcomes of surgically treated posterior pelvic fractures in an Australian population: A multicenter study. Injury. 2025;56(3):112169.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKellam JF, McMurtry RY, Paley D, Tile M. The unstable pelvic fracture. Operative treatment. Orthop Clin North Am. 1987;18(1):25\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTile M. Pelvic ring fractures: should they be fixed? 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Orthop Traumatol Surg Res. 2024;110(2):103691.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiannoudis PV, Tzioupis CC, Pape HC, Roberts CS. Percutaneous fixation of the pelvic ring: an update. J Bone Joint Surg Br. 2007;89(2):145\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenning D, Hackenberg L, Pavlu F, Weber W, Franke A, Kollig E, et al. New Recommendations for the Care of Severely Injured Patients: Revision of the S3 Guideline on Treatment of Polytrauma/Severe Injuries. Z Orthop Unfall. 2024;162(6):630\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiannoudis PV, Grotz MR, Tzioupis C, Dinopoulos H, Wells GE, Bouamra O, et al. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J Trauma. 2007;63(4):875\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOtake K, Tagami T, Tanaka C, Maejima R, Kanaya T, Kido N, et al. Trends in Isolated Pelvic Fracture and 30-Day Survival during a Recent 15-Year Period: A Nationwide Study of the Japan Trauma Data Bank. J Nippon Med Sch. 2022;89(3):309\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndrich S, Haastert B, Neuhaus E, Neidert K, Arend W, Ohmann C, et al. Epidemiology of Pelvic Fractures in Germany: Considerably High Incidence Rates among Older People. PLoS ONE. 2015;10(9):e0139078.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLundin N, Huttunen TT, Berg HE, Marcano A, Fellander-Tsai L, Enocson A. Increasing incidence of pelvic and acetabular fractures. A nationwide study of 87,308 fractures over a 16-year period in Sweden. Injury. 2021;52(6):1410\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuchholtz S, Kuhne CA, Siebert H. Arbeitskreis Umsetzung Weissbuch/Traumanetzwerk in der DA. [Trauma network of the German Association of Trauma Surgery (DGU). Establishment, organization, and quality assurance of a regional trauma network of the DGU]. Unfallchirurg. 2007;110(4):373\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliphant BW, Tignanelli CJ, Napolitano LM, Goulet JA, Hemmila MR. American College of Surgeons Committee on Trauma verification level affects trauma center management of pelvic ring injuries and patient mortality. J Trauma Acute Care Surg. 2019;86(1):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDehli T, Bagenholm A, Johnsen LH, Osbakk SA, Fredriksen K, Bartnes K. [Seriously injured patients transferred from local hospitals to a university hospital]. Tidsskr Nor Laegeforen. 2010;130(15):1455\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Maarseveen OEC, Ham WHW, van de Ven NLM, Saris TFF, Leenen LPH. 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Zhonghua Shao Shang Za Zhi. 2018;34(8):529\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurkhardt M, Kristen A, Culemann U, Koehler D, Histing T, Holstein JH, et al. Pelvic fracture in multiple trauma: are we still up-to-date with massive fluid resuscitation? Injury. 2014;45(Suppl 3):S70\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartinez F, Alegret N, Carol F, Laso MJ, Zancajo J, Garcia E, et al. Pelvic fracture in the patient with multiple injuries: factors and lesions associated with mortality. Emergencias. 2018;30(2):91\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePfeifer R, Klingebiel FK, Balogh ZJ, Beeres FJP, Coimbra R, Fang C, et al. Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process and systematic review. 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Prehosp Emerg Care. 2022;26(4):547\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWohlrath B, Trentzsch H, Hoffmann R, Kremer M, Schmidt-Horlohe K, Schweigkofler U. [Preclinical and clinical treatment of instable pelvic injuries: Results of an online survey]. Unfallchirurg. 2016;119(9):755\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrentzsch H, Lefering R, Schweigkofler U, TraumaRegister DGU. Imposter or knight in shining armor? Pelvic circumferential compression devices (PCCD) for severe pelvic injuries in patients with multiple trauma: a trauma-registry analysis. Scand J Trauma Resusc Emerg Med. 2024;32(1):2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePohlemann T, Gansslen A. The German pelvic database. Arch Orthop Trauma Surg. 2025;145(1):167.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Pelvic fracture, Severe Trauma, Transferral, TraumaRegister DGU®, Level I Trauma center","lastPublishedDoi":"10.21203/rs.3.rs-8774696/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8774696/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003ePelvic fractures are classified as stable or unstable. They correlate with a severity of trauma and the initial medical treatment is decisive. This study evaluated the transferrals of such fractures and described the initial treatment as well as the clinical course.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe analysed retrospective data from a large cohort of the TraumaRegister DGU\u0026reg; (TR-DGU), covering the period from 2014 to 2023, comprising a total of n\u0026thinsp;=\u0026thinsp;397,910 patients. All patients aged\u0026thinsp;\u0026ge;\u0026thinsp;16 years were included. Injury patterns were described according to the Abbreviated Injury Scale (AIS), the mechanically unstable fractures were classified with an AIS\u0026thinsp;\u0026ge;\u0026thinsp;3. We considered all participating hospitals within Germany. The patients were subdivided in three groups: Group 1\u0026thinsp;=\u0026thinsp;primary admitted patients with outcome, group 2\u0026thinsp;=\u0026thinsp;pre-treated patients transferred in from other hospitals, and group 3\u0026thinsp;=\u0026thinsp;primary admitted and early (\u0026lt;\u0026thinsp;48 hours) transferred out.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe majority of the patients was male and about 53 years old. Blunt trauma was the leading trauma mechanism. Concomitant injuries (AIS 2+) affected thorax (56%), spinal cord (41%), lower extremities (38%), head (31%) and abdomen (24%). Among primary admitted cases with pelvic fractures (n\u0026thinsp;=\u0026thinsp;36,398), 21,091 cases (57.9%) had an unstable pelvic fracture (AIS pelvis 3\u0026ndash;5). Level 1 trauma centers not only treated 12,836 primary admitted cases with unstable pelvic fracture (83.5%) but also received 2,365 patients (15.4%) from other hospitals via transfer; only 1% of cases were transferred out early (n\u0026thinsp;=\u0026thinsp;170). Transfusion was applied in 5,984 patients (16.5%) (AIS 2\u0026ndash;5). A pelvic binder was applied in 7,096 (36.3%) patients and surgical stabilisation was performed in 4,075 (14.9%) patients. The length of stay on intensive care unit was highest in AIS 5 with 6 days. The mortality rate was 38.5% in AIS 5, and 9.9% in AIS 2.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe prevalence of unstable pelvic ring fractures (AIS 3\u0026ndash;5) constantly remained around 9%. Unstable pelvic fractures were increasingly transferred to a Level I trauma center. The unstable pelvic fractures correlated with a high the Injury Severity Score (ISS). The early treatment involved the transfusion of packed red blood cells, the application of a pelvic binder and the surgical stabilisation. Though, these tools were increasingly utilized with the severity of trauma.\u003c/p\u003e","manuscriptTitle":"Transferrals and clinical pathways of unstable pelvic fractures over the last 10 years - A retrospective analysis of the Trauma Register DGU®","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-13 16:45:42","doi":"10.21203/rs.3.rs-8774696/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-30T17:18:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-30T14:56:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-06T12:37:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281752888111285965801594004142299706212","date":"2026-03-06T12:05:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51743224575256041123891667910195108424","date":"2026-03-05T19:36:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-08T08:15:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-07T20:55:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-04T05:29:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2026-02-03T09:48:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"71f6eb55-4e0c-4456-bc6e-3304370475c6","owner":[],"postedDate":"February 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-26T09:09:35+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-13 16:45:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8774696","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8774696","identity":"rs-8774696","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}