Background Orthopaedic trauma, particularly extremity fractures from road traffic injuries, is a leading yet under-recognised cause of morbidity in resource-limited settings. In Tanzania, data on fracture patterns, operative timing and system-level delays are limited, hindering evidence-based strategies to strengthen trauma care and surgical capacity. Methods We conducted a prospective multicentre observational cohort study using a real-time trauma registry across five Tanzanian hospitals (June 2023–September 2024). Consecutive orthopaedic trauma patients were included; isolated non-orthopaedic injuries, pathological fractures and deaths on arrival were excluded. Exposures were prehospital, triage and in-hospital delays, interfacility transfer, operative intervention and severity. Primary outcome was 14-day mortality; secondary outcomes included complications, length of stay and functional recovery. Predictors were assessed using multivariable logistic and Cox regression with multiple imputations. Results Among 7121 patients (median age 31 years (IQR 22–44); 6393 (89.8%) male), 4013 (56.4%) were rural residents and 4042 (56.8%) were interfacility transfers. Fractures occurred in 5101 (71.6%) patients, including 2590 (50.8%) open fractures, mostly lower-limb (3116 (61.1%)). 14-day mortality was 771 (10.8%), higher in open fractures (16.4% vs 5.2%) and intensive care unit admissions (25%). Independent mortality predictors included interfacility transfer (adjusted OR (aOR) 1.99; 95% CI 1.73 to 2.32), rural residence (aOR 1.80; 95% CI 1.32 to 2.46) and prolonged prehospital delay (aOR 1.39; 95% CI 1.12 to 1.74). Timely surgery reduced mortality (aOR 0.87; 95% CI 0.78 to 0.97). Among 4028 surgical patients (56.6%), 895 (22.2%) had complications, mainly surgical site infections (312 (7.7%)). Functional recovery at discharge occurred in 4624 of 6350 (72.8%) survivors, with 1856 (29.2%) returning to work or school. Conclusions Orthopaedic trauma in Tanzania caused substantial early mortality, independently linked to prehospital delays, interfacility transfer and rural residence. Timely surgery improved survival, highlighting the need to strengthen referral pathways, expedite care and expand surgical care capacity. A structured electronic trauma registry provided real-world data to guide policy, workforce planning and trauma system development
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