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Synopsis This article presents an overview of perioperative management of the fragility fracture patient including, pre-operative risk stratification and optimization, anesthesia risks and anesthesia options as well as post-operative pain management. It is the intent of this manuscript to communicate the issues of preoperative evaluation which are of concern for the anesthesiologist because of their direct effect on intraoperative care. A team interdisciplinary approach and good communication between specialties involved in care of the elderly surgical patients is important for optimal patient outcomes and to avoid perioperative complications. Cooperation between anesthesiology and medicine is indispensable in reaching a reasonable consensus regarding preoperative evaluation, and should occur on a case-by-case basis.

Spontaneous retroperitoneal hematomas are a rare yet potentially devastating occurrence associated with antiplatelet and anticoagulant therapies. We present a case of a spontaneous retroperitoneal hematoma post-operatively after a total hip arthroplasty surgery performed under a midline approach spinal anesthetic. A 79-year-old male with a BMI of 25.72 kg/m 2 presented for anterior total hip arthroplasty. A midline approach with an uncomplicated spinal anesthetic was performed. On the night of postoperative day 0, the patient received a prophylactic dose of dalteparin. The patient reported back pain, contralateral leg numbness, and weakness that began overnight on postoperative day 0. A computed tomography (CT) scan confirmed a 10 cm, contralateral retroperitoneal hematoma. The patient underwent interventional radiology embolization followed by surgical evacuation and demonstrated improvement in the neurologic function of his affected leg. Despite the rarity of a spontaneous retroperitoneal hematoma formation in the perioperative period, it could be simultaneously evaluated when performing an MRI to rule out spinal hematoma if a patient suffers a post-op neurologic deficit after a neuraxial technique. Understanding the evaluation and timely treatment of patients at risk for a perioperative retroperitoneal hematoma could help clinicians prevent a permanent neurologic deficit.