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Background and Aims High-risk pulmonary embolism (PE) in elderly patients can complicate lower limb fractures, posing a challenge for anesthetic management. We describe a case of how targeted peripheral nerve blocks (PNBs) balanced urgent fracture fixation with thromboembolic risk management in a patient with fracture-related PE.Methods A 92-year-old female proposed for open reduction and internal fixation of a supracondylar femoral fracture presented with acute bilateral PE (PESI class V), type 1 respiratory failure, and new-onset atrial fibrillation. Significant comorbidities included chronic kidney disease and prior cerebrovascular disease. To optimize perioperative management, therapeutic enoxaparin was transitioned to unfractionated heparin preoperatively, with discontinuation 4 hours prior to surgery. We performed a combination of ultrasound-guided PNBs: (1) a femoral nerve block (5 mL mepivacaine 1.5% + 10 mL ropivacaine 0.5%), (2) a lateral femoral cutaneous block (2 mL mepivacaine 1.5% + 3 mL ropivacaine 0.5%), and (3) a transgluteal approach to block both the posterior femoral cutaneous and sciatic nerves (5 mL mepivacaine 1.5% + 10 mL ropivacaine 0.5%). Sensory blockade was confirmed in all target nerve distributions prior to surgical incision. Sedation with propofol was then administered for patient comfort, and mechanical thromboprophylaxis was maintained throughout the procedure.Results Surgery was completed within 80 minutes without complications. Excellent intraoperative anesthesia and postoperative analgesia was achieved, with documented patient satisfaction and no need for rescue analgesia. Anticoagulation with enoxaparin was restarted 12 hours postoperatively. The patient initiated physical rehabilitation on postoperative day 1 and was discharged on day 4.Conclusions Ultrasound-guided PNBs safely avoided neuraxial and general anesthesia risks in this patient with acute PE, permitting timely anticoagulation resumption and early mobilization. The successful outcome underscores the importance of timely surgical fixation in hemodynamically stable patients with fracture-related PE, as it may prevent thromboembolic progression. PNBs can be an alternative as primary anesthetic technique in complex cases.