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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Time-to-treatment is a risk factor for the development of pressure

ulcers in elderly patients with fractures of the pelvis and acetabulum
Annemarie Fritz, Laura Gericke, Andreas Höch, Christoph Josten, Georg Osterhoff∗
Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig 04103, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Fractures of the pelvis and acetabulum are associated with pain and immobilization and,
Accepted 8 December 2019 hence, pose the risk of developing a pressure ulcer - especially in elderly patients. In the literature, in-
Available online xxx
formation on risk factors for the occurrence of pressure ulcers related to geriatric pelvic or acetabulum
fractures is missing.
Methods: Consecutive in-hospital patients aged 55 years or older treated for closed pelvis and/or acetab-
ulum fractures between 2013 and 2017 were retrospectively identified from an institutional prospective
database. Epidemiologic characteristics and patient specifics with special focus on the time from admis-
sion to treatment, duration of hospitalization and comorbidities were retrospectively assessed by chart
review.
Results: During the evaluated interval, 407 patients with isolated fractures of the pelvis or acetabulum
(mean age 78 years, range 55 to 101 years, 69,3% female) were treated. A new pressure ulcer that devel-
oped during the hospitalization was observed in 46/407 patients (11.3%). This included pressure ulcers of
stage 1 in 18/46 cases (39%), stage 2 in 24/46 cases (52%), and stage 3 in 4/46 cases (9%). No stage 4 ul-
cers were seen in this cohort. The mean duration of hospitalization was longer in patients with a pressure
ulcer (25 days, SD 17) than in patients with no ulcers (12 days, SD 9; p < .001). Patients who developed
a pressure ulcer, had waited significantly longer for treatment of their pelvis/acetabulum fracture when
compared to patients without an ulcer (5 days, SD 5 vs. 3 days SD 4, p = =.001). A logistic regression
analysis confirmed “time to treatment” as an independent risk factor for the occurrence of a pressure
ulcer during hospitalization. In an analysis adjusted for the confounders age, male gender, diabetes and
malignancy, the odds ratio to develop a pressure ulcer remained 1.10 (CI 1.03 to 1.19; c-value = 0.774,
p = .008) for each day of waiting treatment.
Conclusion: “Time to treatment” is an independent risk factor for the occurrence of a pressure ulcer dur-
ing hospitalization after a pelvis/acetabulum fracture in elderly patients. Each day of waiting treatment
increases the risk of developing a pressure ulcer by 10%.
© 2019 Elsevier Ltd. All rights reserved.

Introduction cedures. The key challenges of treating geriatric patients include

Geriatric pelvis and acetabulum fractures have become an en-
tity of increased relevance for healthcare systems worldwide due
to an aging population. The majority of pelvis fractures occur in el-
derly patients and their incidence has continuously increased over
the past decades [1, 2]. The injury mechanism of geriatric pelvic
and acetabular fractures is usually a low energy trauma in the
presence of impaired bone quality [3]. Treatment options range
from conservative treatment to percutaneous or open surgical pro-
∗
Corresponding author.
E-mail addresses: georg.osterhoff@medizin.uni-leipzig.de, g.osterhoff@gmx.de (G.
Osterhoff).
pre-existing comorbidities and a general deficiency of physical fit-
ness. In this context, fractures of the pelvis and acetabulum are
associated with pain and immobilization and pose the risk of de-
veloping a pressure ulcer - especially in elderly patients.
Pressure ulcers have been defined by the National Pressure Ul-
cer Advisory Panel (NPUAP) and the European Pressure Ulcer Ad-
visory Panel as localized injury to the skin and/or underlying tis-
sue usually over a bony prominence, as a result of pressure or of
pressure in combination with shear [4]. The bony prominences of
the sacral and hip regions are the most usual locations in adults
[5]. Pressure ulcers mainly affect elderly hospitalized adults. They
are associated with higher mortality rates and increased costs due
to longer hospitalization and an increased need for wound care

https://doi.org/10.1016/j.injury.2019.12.007
0020-1383/© 2019 Elsevier Ltd. All rights reserved.

Please cite this article as: A. Fritz, L. Gericke and A. Höch et al., Time-to-treatment is a risk factor for the development of pressure ulcers
in elderly patients with fractures of the pelvis and acetabulum, Injury, https://doi.org/10.1016/j.injury.2019.12.007
JID: JINJ
ARTICLE IN PRESS [m5G;December 13, 2019;3:49]

2 A. Fritz, L. Gericke and A. Höch et al. / Injury xxx (xxxx) xxx

resources [6, 7]. In a recent study from the UK, the average in- Table 1
Patients’ baseline characteristics.
dividual costs of pressure ulcer treatment ranged from 1386 € for
stage 1 to 16,103 € for stage 4 ulcers [8]. Pressure ulcer P Total
In the existing literature, there is a lack of information regard- Yes No
ing risk factors for the occurrence of pressure ulcers related to N 46 361 407
geriatric patients with pelvic or acetabulum fractures. As these Age 82 (8) 78 (10) .006a 78 (10)
fractures lead to immobilizing pain, it was the authors’ hypothe- Gender [f : m] 25 : 21 257 : 104 .020b 282: 125
Comorbidity
sis that prolonged time-to-treatment would lead to longer immo-
Diabetes 21 (46%) 81 (23%) .001b 102 (25%)
bilization and to more pressure ulcers. Hence, the aim of this study Malignancy 12 (26%) 33 (9%) .001b 45 (11%)
was to evaluate the role of time-to-treatment as a potential risk Braden/admission 16 (4) 18 (3) <0.001a 18 (4)
factor for developing a pressure ulcer during hospitalization. Braden/discharge 14 (4) 19 (4) <0.001a 19 (4)
a
Student’s T-test.
b
Pearson Chi-square test.
Materials and methods

In operatively-treated patients, time-to-treatment was defined

Patients
This study was approved by the local ethics committee.
Consecutive in-hospital patients aged 55 years or older treated
for closed pelvis and/or acetabulum fractures between 2013 and
2017 were retrospectively identified from an institutional prospec-
tive database. In this database, every patient admitted to our hos-
pital with a fracture of the pelvis or the acetabulum is prospec-
tively documented according to a standard protocol as required for
the Pelvic Injury Register of the German Trauma Society. This in-
cluded patients who were referred to our hospital.
Patients with an additional fracture to their lower extrem-
ity, patients with missing records, patients who had undergone
surgery to their pelvis or acetabulum prior to admission, and pa-
tients with a pre-existing pressure ulcer on admission were ex-
cluded. In addition, we excluded patients who had objected to the
use of their personal data. Finally, 407 patients were analyzed for
this study.
Unstable fractures were treated by open or percutaneous fixa-
tion. Partially stable injuries were managed by an initial attempt
of non-operative treatment and open or percutaneous fixation was
performed if mobilization was not possible after extended anal-
gesic and physiotherapeutic therapy.
Open fixation of the pelvis and acetabulum was usually per-
formed through a modified Stoppa approach, rarely through an il-
ioinguinal approach or single windows of it. For posterior column
fixation in displaced acetabular fractures, a Kocher-Langenbeck ap-
proach was used. Percutaneous fixation was the most common
method for posterior pelvic ring fixation (sacro-iliac screw fixation)
or for fixation of minimally displaced acetabular or anterior ring
fractures (ramus screws, LC2 screws, supraacetabular screws).
Data acquisition
Patient specifics and demographic characteristics with special
focus on the time from admission to treatment and duration of
hospitalization, the presence of diabetes mellitus, heart failure and
coronary heart disease, the existence of systemic malignancy, de-
mentia and the Braden Scale were documented.
The Braden Scale-score consists of seven categories (sensory
perception, moisture, activity, mobility, nutrition, friction and shear
and is being documented on day of admission and discharge as a
standard in our institution. Each category is rated on a scale of 1
to 4, (friction and shear 1 to 3) with a possible total of 23 points.
At total score of 9 or less represents a very high risk for the devel-
opment of a pressure ulcer, a score of 10 to 12 a high risk, a score
of 13 to 14 a moderate risk, a score of 15 to 18 a mild risk, and a
total score of 19 to 23 no risk.
Skin conditions were documented on a daily base and staged
according to the Revised NPUAP Pressure Injury Staging System
(Fig. 1) [4].
as the time between admission and surgery. In patients who were
treated non-operatively, this was defined as the time between ad-
mission and a first attempt of mobilization out of the bed under
physiotherapeutic guidance. All patients received pain medication
according to the WHO guidelines beginning at the time of admis-
sion as a standard.
Statistical analysis
Statistical analysis was performed in SPSS 24.0 (SPSS Inc.,
Chicago, IL, USA). Unless otherwise denoted, data was summarized
as mean with standard deviation (SD).
Primary outcome was the occurrence of a new pressure ul-
cer during the hospitalization. The hypothesis was that time to
pelvis/acetabulum fracture treatment is an independent risk fac-
tor for the development of such an ulcer. To assess for potential
confounders, baseline characteristics were compared between pa-
tients with and without pressure ulcers (Table 1). Nominal vari-
ables were associated using Chi-Square tests and Student’s T-test
was used to compare continuous data. As significant associations
were found for age, gender, the presence of diabetes, a systemic
malignancy, an adjusted regression analysis was performed to as-
sess “time to treatment” as a potential independent risk factor for
the occurrence of a pressure ulcer.
To determine the prognostic value of the identified risk factor,
odds ratios (OR) with confidence intervals (CI) of 95% were calcu-
lated and a receiver operating characteristic curve (ROC) analysis
was made with calculation of the area under curve.
Results
During the evaluated interval of 5 years, 407 elderly patients
with isolated fractures of the pelvis or acetabulum (mean age 78
years, range 55 to 101 years, 282 female) met inclusion criteria and
were further analyzed.
As defined by the inclusion criteria, no patient had a pressure
ulcer at the time of admission. A new pressure ulcer that devel-
oped during the hospitalization was observed in 46/407 patients
(11.3%). This included pressure ulcers of stage 1 in 18/46 cases
(39%), stage 2 in 24/46 cases (52%), and stage 3 in 4/46 cases (9%).
No stage 4 ulcers were seen in this cohort.
The mean duration of hospitalization was 14 days (SD 11, range,
1 to 75) and significantly longer in patients with a pressure ulcer
(25 days, SD 17) than in patients with no ulcers (12 days, SD 9;
p < .001). In general, treatment lead to an improvement of mo-
bility and skin status when assessed by the Braden scale (Table 1,
Fig. 2). In patients where a pressure ulcer was observed, however,
the Braden scale worsened from admission to discharge.
The mean time between admission and treatment of the
pelvis/acetabulum fracture was 3 days (SD 4, range 0 to 22). Treat-
ment consisted of non-operative management in 190/407 cases

Please cite this article as: A. Fritz, L. Gericke and A. Höch et al., Time-to-treatment is a risk factor for the development of pressure ulcers
in elderly patients with fractures of the pelvis and acetabulum, Injury, https://doi.org/10.1016/j.injury.2019.12.007
JID: JINJ
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A. Fritz, L. Gericke and A. Höch et al. / Injury xxx (xxxx) xxx 3

Fig. 1. The Revised NPUAP Pressure Injury Staging System [4]. (A) Stage 1: Intact skin with nonblanchable erythema. (B) Stage 2: Partial-thickness skin loss with exposed
dermis. (C) Full-thickness skin loss with subcutaneous fat visible. (D) Stage 4: Full-thickness and tissue loss (schematic image, as no stage 4 lesions were seen in the study
cohort). (D) reprinted with permission of [4].

Fig. 2. Braden scale on admission (blue) and discharge (red) in patients without
(left) and with (right) pressure ulcer. (For interpretation of the references to colour
in this figure legend, the reader is referred to the web version of this article.)

Table 2
Outcome in operative versus non-operative treatment.

Operative Non-operative p

N 217 190 Fig. 3. Receiver operating characteristic (ROC) curve for “time to treatment” as in-
Age 77 (9) 80 (10) .003a dependent risk factor for the development of a pressure ulcer.
Gender [f : m] 131 : 86 152 : 38 <0.001b
Hospital stay 18 (11) 11 (28) .002a
Time to treatment 5 (3.8) 0 (0.4) <0.001a
Braden /admission 18 (3) 18 (4) .080a
patients. The odds ratio to develop a new pressure ulcer was 1.12
Braden /discharge 19 (4) 19 (4) .336a (CI 1.04 to 1.19; p = .002) for each day of waiting for treatment.
Pressure ulcer 30 (13.8%) 16 (8.4%) .116b As age, gender, diabetes, and malignancy also revealed to be asso-
a
Student’s T-test.
ciated with the observation of new pressure ulcers, we performed
b
Pearson Chi-square test. a regression analysis that was adjusted for these four confounders.
In this adjusted analysis, the odds ratio to develop a pressure ulcer
still remained 1.07 (CI 0.962 to 1.18; p = .222; Fig. 3) for each day
(46.6%), percutaneous fixation in 80 (19.7%) and open surgical fix- of waiting treatment.
ation in 137 cases (33.7%). The rate of pressure ulcers was not dif-
ferent between patients who underwent surgery (30/217) and pa-
tients with non-operative treatment (16/190, p = .116; Table 2). Discussion
However, operatively treated patients were younger (p =.003),
waited longer for treatment (p ≤.001), and had a longer hospital The purpose was to evaluate the role of time-to-treatment as a
stay (p = .002). potential risk factor for the development of a pressure ulcer dur-
Patients who developed a pressure ulcer, had waited signif- ing hospitalization after sustaining geriatric pelvic and acetabulum
icantly longer for treatment of their pelvis/acetabulum fracture fractures.
when compared to patients without an ulcer (5 days, SD 5 vs. 3 It was shown that there is no different rate of pressure ulcers
days SD 4, p = =.001). between patients who underwent surgery and patients with non-
In addition, increased age (p = .006), male gender (p = .020), operative treatment. “Time to treatment” was revealed as an in-
and a pre-existing diagnosis of diabetes (p = .001) or a systemic dependent risk factor for the development of a pressure ulcer in
malignancy (p = .001) were all associated with the development elderly patients during hospitalized for pelvis and acetabulum frac-
of a pressure ulcer. tures with an odds ratio of 1.10 for each day of waiting for treat-
A logistic regression analysis confirmed “time to treatment” to ment. In addition, increased age, male gender, diabetes and a sys-
be an independent risk factor for the occurrence of a pressure ulcer temic malignancy were all associated with a higher risk of devel-
during hospitalization after a pelvis/acetabulum fracture in elderly oping a pressure ulcer.

Please cite this article as: A. Fritz, L. Gericke and A. Höch et al., Time-to-treatment is a risk factor for the development of pressure ulcers
in elderly patients with fractures of the pelvis and acetabulum, Injury, https://doi.org/10.1016/j.injury.2019.12.007
JID: JINJ
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4 A. Fritz, L. Gericke and A. Höch et al. / Injury xxx (xxxx) xxx
In this study, a new pressure ulcer developed in 11.3% of the pa-
tients. Similar studies on patients with hip fractures reported sim-
ilar [7] or even higher rates such as 22.7% [9] or 15.4% [10]. As
in other studies, the development of pressure ulcers was linked to
age [9, 11, 12], diabetes [12–14] and systemic malignancy [13]. In
contrast to a study by Lindgren et al. on pressure ulcer risk fac-
tors of patients undergoing surgery, the present study found male
gender to be a risk factor for the development of pressure ulcer
[15]. In the study by Lindgren et al., however, the female patients
were older and of worse general health when compared to the
male patients. Hospitalization time in this cohort was 14 days, this
is longer than reported in other studies on pelvic fractures [16]. A
key reason may be that our institution has no in-house geriatric
department that allows for early referral to a geriatric rehabilita-
tion.
“Time to treatment” was already considered as a risk factor
in studies on patients with hip fractures with various results. A
Swedish study on patients with hip fractures found that reducing
the waiting time for treatment leads to a statistically significant
prevention of pressure ulcers [17] which is consistent with our re-
sults. This is contradicted by Lindholm et al. who could not provide
evidence for a correlation between waiting time for surgery and
the development of pressure ulcers in patients with hip fractures
[11].
The limitations of this study are inherent to its retrospective
design. Even though there exist standardized protocols for the pre-
vention of pressure ulcers in our institution, it is difficult to retro-
spectively assure that these measures were implemented in each
patient. The relatively low incidence of patients with pressure ul-
cers could have made identification of other potential risk factors
difficult. Patients with pressure ulcers present at the time of ad-
mission were excluded for statistical considerations. However, es-
pecially these frail patients with pre-existing ulcers may be at in-
creased risk to develop a second pressure ulcer and, hence, benefit
even more from early treatment.
It is very likely that the fracture patterns in patients with op-
erative and non-operative treatment differed noticeably. As this
study investigated geriatric patients with pelvis and/or acetabulum
fractures, the heterogeneity of the study population did not allow
for fracture pattern related subgroup analyses. In geriatric patients
also a “stable” fracture can be very painful and cause long-lasting
immobilization. Thus, it may be challenging to predict outcome
just from fracture pattern. Non-operatively treated patients may
have had less severe injuries and, hence, might have been mobi-
lized earlier and to a better degree or – lacking the potential ben-
eficial effect of a stabilizing surgical intervention – stayed in bed
for longer. While an attempt to mobilize non-operatively treated
patients was usually made within the first 24 h after admission,
patients scheduled for operative treatment had to stay in bed until
surgery. This analysis also did not account for OR time and ane-
mia as potential risk factors for the development of pressure ul-
cers. More severe fracture patterns may trigger the decision for op-
erative treatment and if so, for more invasive surgical procedures.
This may be associated with longer anesthesia and higher blood
loss. When looking at the outcome in terms of the rate of pressure
ulcers and the Braden scale on admission and discharge, there was
no difference between the operative and non-operative group. In
consequence, no sound conclusions can be drawn from this study
whether operative treatment is beneficial over non-operative treat-
ment.
If the decision for surgery has been made in a certain patient,
however, the intervention should be performed as soon as possible.
Identifying risk factors for the development of pressure ulcers
can help to establish preventive interventions. While most risk fac-
tors like age, gender, and diabetes are risk factor not amenable to a
hospital’s influence, “time to treatment” is very much. This knowl-
Please cite this article as: A. Fritz, L. Gericke and A. Höch et al., Time-to-treatment is a risk factor for the development of pressure ulcers
in elderly patients with fractures of the pelvis and acetabulum, Injury, https://doi.org/10.1016/j.injury.2019.12.007
[m5G;December 13, 2019;3:49]
edge should trigger a reassessment of appropriate treatment flows
of elderly patients with fractures of the pelvis and acetabulum. In
addition, the high rate of pressure ulcers found in this study in-
dicates the need for a better general awareness of the high risk
in this cohort of elderly patients with pelvis and acetabulum frac-
tures. With a Braden scale of mean 16 (i.e. “mild risk”) in patients
that developed an ulcer, this instrument underestimated the risk.
This should be implemented in the education of all individuals in-
volved in the care of these patients – from nurse to surgeon as
early prophylactic measures like daily skin care and special mat-
tresses remain very effective ways to avoid pressure ulcers.
It may be that there exist more risk factors that were not as-
sessed in this study. Future research with larger sample sizes may
adjust for additional risk potential confounders and confirm the
findings of this study for subgroups with open or percutaneous
surgery and allow for better validity and generalisability.
Conclusion
Overall there is no single factor which can explain pressure ul-
cer risk, rather a complex of factors which enhance the probability
of pressure ulcer development. “Time to treatment” was shown to
be an independent risk factor for the occurrence of a pressure ul-
cer during hospitalization after a pelvis/acetabulum fracture in el-
derly patients. Each day of waiting for treatment increases the risk
of developing a pressure ulcer by 10%.
Higher age, male gender and a pre-existing diagnosis of dia-
betes or a systemic malignancy were also associated with a devel-
opment of a pressure ulcer after geriatric pelvic and acetabulum
fractures in this cohort.
Declaration of Competing Interest
None.
References
[1] Boufous S, Finch C, Lord S, et al. The increasing burden of pelvic fractures in
older people, New South Wales, Australia. Injury 2005;36(11):1323–9. doi:10.
1016/j.injury.20 05.02.0 08.
[2] Hill RM, Robinson CM, Keating JF. Fractures of the pubic rami. Epidemiology
and five-year survival. J Bone Joint Surg Br 2001;83(8):1141–4.
[3] Osterhoff G, Werner CML. Die beckenringfraktur des älteren menschen (Pelvic
ring fractures in the elderly). Praxis (Bern 1994) 2015;104(22):1195–202.
[4] Edsberg LE, Black JM, Goldberg M, et al. Revised national pressure ulcer advi-
sory panel pressure injury staging system: revised pressure injury staging sys-
tem. J Wound Ostomy Continence Nurs 2016;43(6):585–97. doi:10.1097/WON.
0 0 0 0 0 0 0 0 0 0 0 0 0281.
[5] Vangilder C, Macfarlane GD, Meyer S. Results of nine international pres-
sure ulcer prevalence surveys: 1989 to 2005. Ostomy Wound Manage
2008;54(2):40–54.
[6] Bauer K, Rock K, Nazzal M, et al. Pressure ulcers in the united states’ inpatient
population from 2008 to 2012: results of a retrospective nationwide study. Os-
tomy Wound Manage 2016;62(11):30–8.
[7] Magny E, Vallet H, Cohen-Bittan J, et al. Pressure ulcers are associated
with 6-month mortality in elderly patients with hip fracture managed
in orthogeriatric care pathway. Arch Osteoporos 2017;12(1):77. doi:10.1007/
s11657- 017- 0365- 9.
[8] Dealey C, Posnett J, Walker A. The cost of pressure ulcers in the United King-
dom. J Wound Care 2012;21(6):261–2 264, 266. doi:10.12968/jowc.2012.21.6.
261.
[9] Chiari P, Forni C, Guberti M, et al. Predictive factors for pressure ulcers in an
older adult population hospitalized for hip fractures: a prognostic cohort study.
PLoS ONE 2017;12(1):e0169909. doi:10.1371/journal.pone.0169909.
[10] Forni C, D’Alessandro F, Gallerani P, et al. Effectiveness of using a new
polyurethane foam multi-layer dressing in the sacral area to prevent the on-
set of pressure ulcer in the elderly with hip fractures: a pragmatic randomised
controlled trial. Int Wound J 2018;15(3):383–90. doi:10.1111/iwj.12875.
[11] Lindholm C, Sterner E, Romanelli M, et al. Hip fracture and pressure ulcers -
the Pan-European pressure ulcer study - intrinsic and extrinsic risk factors. Int
Wound J 2008;5(2):315–28. doi:10.1111/j.1742-481X.20 08.0 0452.x.
[12] Lima Serrano M, González Méndez MI, Carrasco Cebollero FM, et al. Factores
de riesgo asociados al desarrollo de úlceras por presión en unidades de cuida-
dos intensivos de adultos: revisión sistemática (Risk factors for pressure ul-
cer development in intensive care units: a systematic review). Med Intensiva
2017;41(6):339–46. doi:10.1016/j.medin.2016.09.003.
JID: JINJ
ARTICLE IN PRESS [m5G;December 13, 2019;3:49]

A. Fritz, L. Gericke and A. Höch et al. / Injury xxx (xxxx) xxx 5

[13] Margolis DJ, Knauss J, Bilker W, et al. Medical conditions as risk factors for
pressure ulcers in an outpatient setting. Age Ageing 2003;32(3):259–64.
[14] Børsting TE, Tvedt CR, Skogestad IJ, et al. Prevalence of pressure ulcer and as-
sociated risk factors in middle- and older-aged medical inpatients in Norway. J
Clin Nurs 2018;27(3–4):e535–43. doi:10.1111/jocn.14088.
[15] Lindgren M, Unosson M, Krantz A-M, et al. Pressure ulcer risk factors in
patients undergoing surgery. J Adv Nurs 2005;50(6):605–12. doi:10.1111/j.
1365-2648.2005.03441.x.
[16] Moral-Cuesta D, Rodríguez-Sánchez I, Menéndez-Colino R, et al. Impacto fun-
cional de la fractura de pelvis por fragilidad. Descripción de una serie de ca-
sos consultados al servicio de Geriatría (Functional consequences of fragile
pelvis fracture. Description of several cases attended by a consultation Geri-
atrics team). Rev Esp Geriatr Gerontol 2018;53(2):81–4. doi:10.1016/j.regg.2017.
06.002.
[17] Hommel A, Ulander K, Thorngren K-G. Improvements in pain relief, handling
time and pressure ulcers through internal audits of hip fracture patients. Scand
J Caring Sci 2003;17(1):78–83.

Please cite this article as: A. Fritz, L. Gericke and A. Höch et al., Time-to-treatment is a risk factor for the development of pressure ulcers
in elderly patients with fractures of the pelvis and acetabulum, Injury, https://doi.org/10.1016/j.injury.2019.12.007