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Background and Aims Distal femur fractures represent approximately 4–6% of all femoral fractures, primarily affecting elderly due to osteoporosis and fall risk. Surgical fixation is the standard treatment but poses anesthetic challenges, especially in patients with multiple comorbidities. While spinal anesthesia is preferred, peripheral nerve blocks offer a viable alternative in high-risk patients, minimizing systemic complications and providing effective perioperative analgesia.Methods A 66-year-old female with medical history of coronary artery disease, hypertension, type 2 diabetes mellitus, chronic kidney disease, liver cirrhosis with portal hypertension, esophageal varices, chronic anemia, and a recent episode of hepatic encephalopathy presented with a right distal femur fracture. Her coagulation profile showed an INR of 1.4 and prolonged PT. Given the high anesthetic risk, the decision was made to perform the surgery under regional anesthesia alone. Anesthetic Technique: Sciatic nerve block (anterior approach) (15 ml of 0.25% Levobupivacaine) Femoral nerve block (15 ml 0.25% levobupivacaine) Lateral femoral cutaneous nerve block (4 ml 0.125% Levobupivacaine) Obturator nerve block (anterior branch) (8 ml of 0.25% Levobupivacaine) Procedural sedation included a single 20 mg dose of ketamine and propofol infusion at 153 mg/hr. Hemodynamic stability was maintained with phenylephrine infusion.Results Patient was monitored in PACU and did not require SICU admission. Two units packed RBCs transfused due to postoperative anemia. She remained stable throughout and experienced no anesthesia-related complications. Patients with liver disease, coagulopathy, and recent encephalopathy are at increased risk with both general and neuraxial anesthesia. Peripheral nerve blocks, when used appropriately and with proper monitoring, offer a targeted and safe alternative. Regional anesthesia also reduces opioid requirements, facilitating recovery and minimizing respiratory and cognitive complications, especially in elderly.Conclusions Peripheral nerve blocks can serve as an effective sole anesthetic technique in high-risk geriatric patients undergoing lower limb orthopedic surgery. This approach should be considered in patients for whom general or spinal anesthesia poses significant risk.