Anesthesia management of bilateral femur shaft fracture and left tibiofibular fracture for bilateral sign nail and tibiofibular sign with cervical spine injury and epidural hematoma: a case report

Anesthesia management of bilateral femur shaft fracture and left tibiofibular fracture for bilateral sign nail and tibiofibular sign with cervical spine injury and epidural hematoma: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Anesthesia management of bilateral femur shaft fracture and left tibiofibular fracture for bilateral sign nail and tibiofibular sign with cervical spine injury and epidural hematoma: a case report Shitalem Tadesse, Tenbite Daniel This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3946339/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Preoperative evaluation by an anesthetist must be performed since 70% of patients with a femur fracture will have an American Society of Anesthesiologists (ASA) score of III to IV. Although they occur rarely between 1 and 7%, bilateral femur fractures are linked to significant morbidity and mortality. Previous reports have described anesthetic management for aged patients who have bilateral femur fracture is difficult and needs team and increased perioperative complications. This case emphasizes the necessity to prepare adequately and improve knowledge and awareness of anesthetic management of patients for bilateral femur fracture and tibiofibular fracture for aged patients and needs multidisciplinary team to cooperate and increase the positive outcome of the patients. Patients with these conditions may present with various sign and symptoms that complicate the administration of anesthesia. Decisions regarding when to operate either before resuscitation or after the patient is resuscitated are one area of concern and consider preserving organ damage from secondary complications and maintain hemodynamic stability to ensure the anesthesia management is optimal and to increase the good outcomes of the patient. Case report : A 50 year old male presented with bilateral femur shaft fracture and left tibiofibular fracture following road traffic accident and was planned for bilateral sign nail and left tibiofibular sign. Patient has cervical spine injury and epidural hematoma. Patient has undergone general anesthesia with endotracheal tube. Conclusion : We present a successful anesthetic management of patients who had bilateral femur fracture and left tibiofibular fracture with cervical spine injury and epidural hematoma. We emphasize the risk of neurological injury while extending the neck during laryngoscopy for tracheal intubation due to cervical spine injuries and we preferred to general anesthesia over spinal anesthesia due to contraindicated for spinal anesthesia in these patients. A detailed pre anesthetic evaluation and multidisciplinary approach as well as planning is utmost important and the anesthetic technique has to be individualized based on the patients anatomical characteristics and associated co-morbidities. Bilateral femur shaft fracture anesthetic management aged tibiofibular sign nail cervical spine injury hematoma road traffic accident 1. Introduction Bilateral femur fractures are relatively rare (1–7%), they are associated with high morbidity and mortality ( 1 ).Seventy percent of patients with a femur fracture will have an American Society of Anesthesiologists (ASA) score of 3 to 4, making preoperative assessment by an anesthetist mandatory ( 2 ). The best treatment for bilateral fractures is still debated, with few recommendations found in the literature. Acute respiratory distress syndrome (ARDS) is the most feared complication ( 3 ). Simultaneous bilateral neck of femur fracture is a rare entity and is often seen in patients with metabolic diseases like osteomalacia, renal osteodystrophy, after epileptic attacks, electrical shock or trauma ( 4 ). Simultaneous traumatic bilateral neck femur fractures are even rarer and there is very few case reports published wherein fracture occurred due to low energy impact ( 5 ). Unilateral fracture neck femurs are commonly seen in young adults after high energy injury and in elderly patients after low energy injury. Bilateral femur neck fracture occur following road traffic accidents and high energy trauma such as fall from a height has been reported in literature but its association with low energy injuries like a fall at home is very rare. The anaesthetic assessment allows for planning of anesthetic technique, assessment and communication of perioperative risk, and preoptimisation. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) recommend that peripheral nerve blockade always be considered whether a spinal or general anesthesia is used. 2. Case presentation Preoperatively This is a 50 years old 60 kg male ASA III patient presented with road traffic accident when he was driving a car, he had loss of consciousness at that time and had mild traumatic brain injury, neck injury and he was on cervical collar associated to this he had blunt chest injury indicative of lung contusion and had chest pain and the pain worsen when he tried to breath and ambulate and also the patient had bleeding at the time of accident. Otherwise he has no history of chronic medical illness like diabetes mellitus, hypertension, respiratory disease, neurologic disease like epilepsy, he has no history of cigarette smoking and alcohol consumption, no history of current medication intake, no history of allergy, no history of upper respiratory tract infections, no previous history of surgery and anesthesia. On physical examination the patient was acute sick looking on intranasal O2 with 3L with spo2 of 93% and vital sign was blood pressure 110/70 mmHg, pulse rate 93 beats per minute, respiratory rate 20 breaths per minute and temperature 36.7 o C. The patient has slightly pale conjunctiva and his mallampati score was II and difficult to assess the other airway parameters due to rigid cervical collars. During preoperative evaluation the cardiorespiratory system, genitourinary and gastrointestinal system was normal but on musculoskeletal system he had severe tenderness on both legs and had long posterior gutter on both legs. Brain CT shows there are two epidural blood collections: 1st : left parietal with a thickness of 5.5 mm, 2nd left temporal with a thickness of 6.1 mm, on cervical spine CT there is C7 left lateral mass facet transverse process fracture plus C6 left lateral mass fracture. Laboratory investigation of the patient was described below (Table 1 ). Then with appropriate communication with surgical team we prepared cross match blood for intraoperative and an intensive care unit for postoperative follow up and the patient transferred from the ward to the operation room via stretcher. Table 1 preoperative laboratory investigation of the patient Laboratory investigation Components Result Complete blood count White blood cell count 10.1x10 6 /mcL Neutrophil 71.1% Hemoglobin 10.7 gm/dl hematocrit 30.2% Platelet 198k mm 3 Blood group and Rh O positive Serum electrolytes Sodium 127mEq/l Potassium 4.3 mEq/l Chloride 96 mEq/l Liver function tests Aspartate aminotransferase 38 mmol/l Alkaline phosphatase 65 mmol/l Renal function tests Serum creatinine 1.2 mg/dl Blood urea nitrogen 18.2 mg/dl Intraoperatively After the patient arrived to the operation room for an indication of bilateral femoral sign nail and left distal tibiofibular sign nail an informed consent was taken and then monitors attached like NIBP, ECG and pulse oximetry and arterial line for invasive blood pressure monitoring. The initial vital sign was BP: 125/70 mmHg, PR: 91 BPM, Spo2:97% then planned to proceed with general anesthesia with endotracheal intubation and initially premedicated with fentanyl 100mcg, morphine 3mg,ceftriazone 1gm, then the induction agent was ketamine 50mg and propofol 70mg,for facilitation of intubation suxamethonium chloride 120mg. The patient intubated after preoxygenation with 10 LPM for 5 minutes one anesthesia provider released the cervical collar after the patient induced and the cervical spine maintained with manual inline stabilization and intubated with endotracheal tube of 7.5 mm and laryngoscope blade of size four then the neck maintained in neutral position and the tube fixed with tape and the chest checked for bilateral breath sound then the surgery started. Anesthesia was maintained with isoflurane range from 0.5–1% and for muscle relaxant vecronium given with a total dose of 12 mg and then the patient also received 1g of tranexamic acid. During the intraoperative period he was hemodynamically stable and his RBS at the mid of surgery was 112 mg/dl. The patient receives a total of 2000ml normal saline and 1000 ml ringer lactate with intraoperative blood loss of around 724 ml and urine output of 1300ml. Neuromuscular relaxant was reversed with atropine 1mg and neostigmine 2.5mg. For postoperative management bilateral fascia iliaca compartment block (FICB) with 25 ml of 0.25% bupivacaine bilaterally and lateral approach popliteal nerve block using 20 ml of 0.25% bupivacaine given. Duration of surgery and anesthesia was 3 hours and 35 minutes and 4 hours 40 minutes respectively. Postoperatively After the end of the surgery the patient did not fulfill the criteria to extubate then planned to transfer the patient to ICU with ambubag with adequate preparation including emergency drugs and ventilating the patient with ambubag then the ICU was already prepared and the patient put on mechanical ventilation on pressure support ventilation (PSV) mode then the hemodynamics was normal with vital sign of BP: 108/68 mmHg, PR: 75 BPM and SPO2 of 99%. After two hours the patient tried to maintain his saturation and had adequate breathing pattern, then the ICU anesthesiologist extubated the patient with adequate trying of his tolerance to extubation. Fourteen days later he was discharged from the hospital and advised to follow up. 3. Discussion Few occurrences of bilateral femur and tibiofibular fractures have been documented in the literature, making them uncommon conditions. The most common causes of these fractures are falls from a height or high impact injuries ( 6 ). One infrequent cause of bilateral femur neck fractures is uncomplicated trauma ( 7 ). Few cases of bilateral femur neck fractures in elderly people after minor trauma have been documented ( 8 ). In older patients, peri-operative hypotension may be linked to both spinal anesthetic and general anesthesia ( 9 ). According to Seidel et al stated that the associated effort and requirement for expert knowledge in regional anesthesia indicates that regional anesthesia should be considered especially in cases with high anesthetic risk, suitable sonoanatomy, and non-compromised coagulation ( 10 ). Parker et al stated that most proximal femur fracture patients are older, and their condition is treated surgically, requiring general anesthesia. Simple falls are typically the cause of the fracture. These patients are at a higher risk of dying after anesthesia because they frequently have numerous additional age-related medical conditions ( 11 ). Huang et al stated that compared to elderly patients under general anesthesia, those who had femur neck fracture surgery under fascia iliaca compartment block with total intravenous anesthesia needed fewer intensive care unit admissions, spent less time in the intensive care unit and hospital after surgery, and used less opioids afterward( 12 ). Chen et al stated that as compared to regional anesthesia, general anesthetic for elderly patients undergoing hip fracture surgery was linked to a higher risk of in-hospital death, acute respiratory failure, length of stay in the hospital, and readmission. For postoperative pneumonia, heart failure, acute myocardial infarction, acute renal failure, cerebrovascular accident, delirium, and deep venous thrombosis and or pulmonary embolism a significant difference was not, however, obtained ( 13 ). Ollerton et al stated that Manual in-line stabilization (MILS) of the cervical spine is the recommended technique to immobilize the cervical spine. This entails firmly holding the patient either side of the head with the neck in the midline and the head on a firm trolley surface. Traction is not applied and the aim is to prevent any flexion or rotation of the c‐spine when laryngoscopy is performed. To facilitate the airway specialist, the assistant needs to crouch by the trolley, slightly to one side, while intubation is performed. The cervical collar may be loosened or the anterior portion temporarily removed to facilitate mouth opening and application of cricoid pressure ( 14 ). Meschino et al stated that awake intubation is preferred for such patient category and has an advantage of decreased threat of aspiration, patient protection the injury site by splinting and immediate awareness of the any worsening of the neurologic symptoms ( 15 ). Makris et al stated that the risk of spinal epidural hematoma must be addressed if neurological symptoms emerge in the postoperative period, especially after a neuraxial blockade. This issue may have a direct or indirect relationship with the anesthetic technique ( 16 ). Domenicucci Stated that 18% of patients who have spinal epidural hematoma caused by iatrogenic factors such as coagulopathy or spinal puncture and may aggravate the clinical conditions of patient who have epidural hematoma ( 17 ). 4. Conclusion In conclusion bilateral femur fractures and tibiofibular fractures with cervical spine injury and epidural hematoma are extremely rare and may occur also in elderly patient with a specific mechanism of injury. Perioperative anesthesia management for such patient is difficult and needs team working and done in multidisciplinary approach. General anesthesia for bilateral femur fracture and tibiofibular fracture who had epidural hematoma and cervical injury had better than spinal anesthesia due to spinal anesthesia is contraindicated in patients who have hematoma and patients unable to sit or to position in lateral position and thus considered as anesthetic of choice for patients who had trauma to the brain and spinal cord. Declarations Ethical approval and consent to participate Ethical approval not needed Consent for publication “Written informed consent was obtained from the patient for publication of this case report.” under consent to publication. Availability of data and materials Data are available from Shitalem Tadesse , [email protected] for researchers who meet the criteria for access to confidential data. Competing interest No conflict of interest Funding No any financial support from organizations Authors’ contributions Shitalem Tadesse contributes for the preparation of the main manuscript and make ready for publication Tenbite Daniel contributes for review and comments of the manuscript during manuscript preparation Acknowledgment The authors would like to express deepest appreciation to the patient and his family and we would also like to extend deepest gratitude to Mrs. Hana Eshetu for review and comments of the manuscript during manuscript preparation. Authors’ information 1 Debre Berhan University, Asrat Woldeyes Health Science Campus, Department of Anesthesia lecturer, Debre Berhan, Ethiopia 2 Addis Ababa University, College of Medicine, School of Anesthesia, Department of Anesthesia Assistant professor and lecturer , Addis Ababa, Ethiopia References Willett K, HAl-Khateeb R, Kotnis O, Bouamra F. Lecky Risk of mortality: the relationship with associated injuries and fracture treatment methods in patients with unilateral or bilateral femoral shaft fractures. J Trauma. 2010;69:405. Gurkan I, Wenz JF. Perioperative infection control: an update for patient safety in orthopaedic surgery. Orthopedics. 2006;29:329–39. Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME. Pollak External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma. 2000;48:613–21. Nordt SP, Clark RF. Midazolam: a review of therapeutic uses and toxicity. J Emerg Med. 1997;15(3):357–65. Nucera E, Aruanno A, Buonomo A, Parrinello G, Rizzi A. Hypersensitivity reaction to midazolam: a case of 4 Case Reports in Anesthesiology cardio-respiratory failure, Advances in Dermatology and A llergology , vol. 37, no. 6, pp. 1012–1013, 2020. Carrell B, Carrell WB. Fractures in the neck of the femur in children with particular reference to aseptic necrosis. JBJS. 1941;23(2):225–39. Powell HDW. Simultaneous bilateral fractures of the neck of the femur. J Bone Joint Surg Br. 1960;42–B(2):236–52. 10.1302/0301-620X.42B2.236 . Dhar D. 2013. Bilateral traumatic fracture of neck of femur in a child: a case report. Malaysian Orthopaedic Journal , 7 (2), p.34. Wood RJ, White SM. Anaesthesia for 1131 patients undergoing proximal femoral fracture repair: a retrospective, observational study of effects on blood pressure, fluid administration and perioperative anaemia. Anaesthesia. 2011;66(11):1017–22. Seidel R, Barbakow E, Schulz-Drost S. 2021. Surgical treatment of proximal femoral fractures in high-risk geriatric patients under peripheral regional anesthesia: A prospective feasibility study. Anästhesist, 70 (12). Parker MJ, Handoll HH, Griffiths R. 2004. Anaesthesia for hip fracture surgery in adults. Cochrane Database of Systematic Reviews , (4). Huang YY, Hui CK, Lau NC, Ng YT, Lin TY, Chen CH, Wang YC, Tang HC, Chen DWC, Chang CW. 2023. Total intravenous anesthesia for geriatric hip fracture with severe systemic disease. Eur J Trauma Emerg Surg, pp.1–7. Chen DX, Yang L, Ding L, Li SY, Qi YN, Li Q. 2019. Perioperative outcomes in geriatric patients undergoing hip fracture surgery with different anesthesia techniques: A systematic review and meta-analysis. Medicine, 98 (49). Ollerton JE, Parr MJA, Harrison K, Hanrahan B, Sugrue M. 2006. Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department—a systematic review. Emergency Medicine Journal: EMJ , 23 (1), p.3. Meschino A, Devitt JH, Koch JP, Szalai JP, Schwartz ML. The safety of awake tracheal intubation in cervical spine injury. Can J Anaesth. 1992;39:114–7. Makris A, Gkliatis E, Diakomi M, Karmaniolou I, Mela A. Delayed spinal epidural hematoma following spinal anesthesia, far from needle puncture site. Spinal Cord. 2014;52(1):S14–6. Domenicucci M, Mancarella C, Santoro G, Dugoni DE, Ramieri A, Arezzo MF, Missori P. Spinal epidural hematomas: personal experience and literature review of more than 1000 cases. J Neurosurgery: Spine. 2017;27(2):198–208. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3946339","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":274826221,"identity":"9647fed9-d4de-4a37-a927-620c681d2f60","order_by":0,"name":"Shitalem Tadesse","email":"data:image/png;base64,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","orcid":"","institution":"Debre Berhan University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Shitalem","middleName":"","lastName":"Tadesse","suffix":""},{"id":274826222,"identity":"990eaa2b-6168-4f0d-a836-de34dbbc4990","order_by":1,"name":"Tenbite Daniel","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tenbite","middleName":"","lastName":"Daniel","suffix":""}],"badges":[],"createdAt":"2024-02-10 16:44:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3946339/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3946339/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60142733,"identity":"a28e9ca9-3f51-43fb-a519-6f387123f862","added_by":"auto","created_at":"2024-07-12 09:22:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":309272,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3946339/v1/01bf051c-1948-4d76-84ad-c361f64e7221.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anesthesia management of bilateral femur shaft fracture and left tibiofibular fracture for bilateral sign nail and tibiofibular sign with cervical spine injury and epidural hematoma: a case report","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eBilateral femur fractures are relatively rare (1\u0026ndash;7%), they are associated with high morbidity and mortality (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).Seventy percent of patients with a femur fracture will have an American Society of Anesthesiologists (ASA) score of 3 to 4, making preoperative assessment by an anesthetist mandatory (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The best treatment for bilateral fractures is still debated, with few recommendations found in the literature. Acute respiratory distress syndrome (ARDS) is the most feared complication (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Simultaneous bilateral neck of femur fracture is a rare entity and is often seen in patients with metabolic diseases like osteomalacia, renal osteodystrophy, after epileptic attacks, electrical shock or trauma (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Simultaneous traumatic bilateral neck femur fractures are even rarer and there is very few case reports published wherein fracture occurred due to low energy impact (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Unilateral fracture neck femurs are commonly seen in young adults after high energy injury and in elderly patients after low energy injury. Bilateral femur neck fracture occur following road traffic accidents and high energy trauma such as fall from a height has been reported in literature but its association with low energy injuries like a fall at home is very rare. The anaesthetic assessment allows for planning of anesthetic technique, assessment and communication of perioperative risk, and preoptimisation. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) recommend that peripheral nerve blockade always be considered whether a spinal or general anesthesia is used.\u003c/p\u003e"},{"header":"2. Case presentation","content":"\u003cp\u003e \u003cb\u003ePreoperatively\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis is a 50 years old 60 kg male ASA III patient presented with road traffic accident when he was driving a car, he had loss of consciousness at that time and had mild traumatic brain injury, neck injury and he was on cervical collar associated to this he had blunt chest injury indicative of lung contusion and had chest pain and the pain worsen when he tried to breath and ambulate and also the patient had bleeding at the time of accident. Otherwise he has no history of chronic medical illness like diabetes mellitus, hypertension, respiratory disease, neurologic disease like epilepsy, he has no history of cigarette smoking and alcohol consumption, no history of current medication intake, no history of allergy, no history of upper respiratory tract infections, no previous history of surgery and anesthesia. On physical examination the patient was acute sick looking on intranasal O2 with 3L with spo2 of 93% and vital sign was blood pressure 110/70 mmHg, pulse rate 93 beats per minute, respiratory rate 20 breaths per minute and temperature 36.7 \u003csup\u003eo\u003c/sup\u003eC. The patient has slightly pale conjunctiva and his mallampati score was II and difficult to assess the other airway parameters due to rigid cervical collars. During preoperative evaluation the cardiorespiratory system, genitourinary and gastrointestinal system was normal but on musculoskeletal system he had severe tenderness on both legs and had long posterior gutter on both legs. Brain CT shows there are two epidural blood collections: 1st : left parietal with a thickness of 5.5 mm, 2nd left temporal with a thickness of 6.1 mm, on cervical spine CT there is C7 left lateral mass facet transverse process fracture plus C6 left lateral mass fracture. Laboratory investigation of the patient was described below (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThen with appropriate communication with surgical team we prepared cross match blood for intraoperative and an intensive care unit for postoperative follow up and the patient transferred from the ward to the operation room via stretcher.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003epreoperative laboratory investigation of the patient\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaboratory investigation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComponents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eComplete blood count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhite blood cell count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.1x10\u003csup\u003e6\u003c/sup\u003e/mcL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeutrophil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHemoglobin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.7 gm/dl\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ehematocrit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePlatelet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e198k mm\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlood group and Rh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eO positive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSerum electrolytes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSodium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127mEq/l\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePotassium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.3 mEq/l\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChloride\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96 mEq/l\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLiver function tests\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAspartate aminotransferase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 mmol/l\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlkaline phosphatase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 mmol/l\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRenal function tests\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSerum creatinine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2 mg/dl\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlood urea nitrogen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.2 mg/dl\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eIntraoperatively\u003c/b\u003e \u003c/p\u003e \u003cp\u003e After the patient arrived to the operation room for an indication of bilateral femoral sign nail and left distal tibiofibular sign nail an informed consent was taken and then monitors attached like NIBP, ECG and pulse oximetry and arterial line for invasive blood pressure monitoring. The initial vital sign was BP: 125/70 mmHg, PR: 91 BPM, Spo2:97% then planned to proceed with general anesthesia with endotracheal intubation and initially premedicated with fentanyl 100mcg, morphine 3mg,ceftriazone 1gm, then the induction agent was ketamine 50mg and propofol 70mg,for facilitation of intubation suxamethonium chloride 120mg. The patient intubated after preoxygenation with 10 LPM for 5 minutes one anesthesia provider released the cervical collar after the patient induced and the cervical spine maintained with manual inline stabilization and intubated with endotracheal tube of 7.5 mm and laryngoscope blade of size four then the neck maintained in neutral position and the tube fixed with tape and the chest checked for bilateral breath sound then the surgery started. Anesthesia was maintained with isoflurane range from 0.5\u0026ndash;1% and for muscle relaxant vecronium given with a total dose of 12 mg and then the patient also received 1g of tranexamic acid. During the intraoperative period he was hemodynamically stable and his RBS at the mid of surgery was 112 mg/dl. The patient receives a total of 2000ml normal saline and 1000 ml ringer lactate with intraoperative blood loss of around 724 ml and urine output of 1300ml. Neuromuscular relaxant was reversed with atropine 1mg and neostigmine 2.5mg. For postoperative management bilateral fascia iliaca compartment block (FICB) with 25 ml of 0.25% bupivacaine bilaterally and lateral approach popliteal nerve block using 20 ml of 0.25% bupivacaine given. Duration of surgery and anesthesia was 3 hours and 35 minutes and 4 hours 40 minutes respectively.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePostoperatively\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAfter the end of the surgery the patient did not fulfill the criteria to extubate then planned to transfer the patient to ICU with ambubag with adequate preparation including emergency drugs and ventilating the patient with ambubag then the ICU was already prepared and the patient put on mechanical ventilation on pressure support ventilation (PSV) mode then the hemodynamics was normal with vital sign of BP: 108/68 mmHg, PR: 75 BPM and SPO2 of 99%. After two hours the patient tried to maintain his saturation and had adequate breathing pattern, then the ICU anesthesiologist extubated the patient with adequate trying of his tolerance to extubation. Fourteen days later he was discharged from the hospital and advised to follow up.\u003c/p\u003e"},{"header":"3. Discussion","content":"\u003cp\u003eFew occurrences of bilateral femur and tibiofibular fractures have been documented in the literature, making them uncommon conditions. The most common causes of these fractures are falls from a height or high impact injuries (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). One infrequent cause of bilateral femur neck fractures is uncomplicated trauma (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Few cases of bilateral femur neck fractures in elderly people after minor trauma have been documented (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In older patients, peri-operative hypotension may be linked to both spinal anesthetic and general anesthesia (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). According to Seidel et al stated that the associated effort and requirement for expert knowledge in regional anesthesia indicates that regional anesthesia should be considered especially in cases with high anesthetic risk, suitable sonoanatomy, and non-compromised coagulation (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Parker et al stated that most proximal femur fracture patients are older, and their condition is treated surgically, requiring general anesthesia. Simple falls are typically the cause of the fracture. These patients are at a higher risk of dying after anesthesia because they frequently have numerous additional age-related medical conditions (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Huang et al stated that compared to elderly patients under general anesthesia, those who had femur neck fracture surgery under fascia iliaca compartment block with total intravenous anesthesia needed fewer intensive care unit admissions, spent less time in the intensive care unit and hospital after surgery, and used less opioids afterward(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Chen et al stated that as compared to regional anesthesia, general anesthetic for elderly patients undergoing hip fracture surgery was linked to a higher risk of in-hospital death, acute respiratory failure, length of stay in the hospital, and readmission. For postoperative pneumonia, heart failure, acute myocardial infarction, acute renal failure, cerebrovascular accident, delirium, and deep venous thrombosis and or pulmonary embolism a significant difference was not, however, obtained (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOllerton et al stated that Manual in-line stabilization (MILS) of the cervical spine is the recommended technique to immobilize the cervical spine. This entails firmly holding the patient either side of the head with the neck in the midline and the head on a firm trolley surface. Traction is not applied and the aim is to prevent any flexion or rotation of the c‐spine when laryngoscopy is performed. To facilitate the airway specialist, the assistant needs to crouch by the trolley, slightly to one side, while intubation is performed. The cervical collar may be loosened or the anterior portion temporarily removed to facilitate mouth opening and application of cricoid pressure (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Meschino et al stated that awake intubation is preferred for such patient category and has an advantage of decreased threat of aspiration, patient protection the injury site by splinting and immediate awareness of the any worsening of the neurologic symptoms (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Makris et al stated that the risk of spinal epidural hematoma must be addressed if neurological symptoms emerge in the postoperative period, especially after a neuraxial blockade. This issue may have a direct or indirect relationship with the anesthetic technique (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Domenicucci Stated that 18% of patients who have spinal epidural hematoma caused by iatrogenic factors such as coagulopathy or spinal puncture and may aggravate the clinical conditions of patient who have epidural hematoma (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e"},{"header":"4. Conclusion","content":"\u003cp\u003eIn conclusion bilateral femur fractures and tibiofibular fractures with cervical spine injury and epidural hematoma are extremely rare and may occur also in elderly patient with a specific mechanism of injury. Perioperative anesthesia management for such patient is difficult and needs team working and done in multidisciplinary approach. General anesthesia for bilateral femur fracture and tibiofibular fracture who had epidural hematoma and cervical injury had better than spinal anesthesia due to spinal anesthesia is contraindicated in patients who have hematoma and patients unable to sit or to position in lateral position and thus considered as anesthetic of choice for patients who had trauma to the brain and spinal cord.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval not needed\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Written informed consent was obtained from the patient for publication of this case report.\u0026rdquo; under consent to publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available from Shitalem Tadesse ,[email protected] \u0026nbsp;for researchers who meet the criteria for access to confidential data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo conflict of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo any financial support from organizations\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eShitalem Tadesse contributes for the preparation of the main manuscript and make ready for publication\u003c/p\u003e\n\u003cp\u003eTenbite Daniel contributes\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003efor review and comments of the manuscript during manuscript preparation\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors\u0026nbsp;would like to express deepest appreciation to\u0026nbsp;the patient and his family and we\u0026nbsp;would also like to extend deepest gratitude to\u0026nbsp;Mrs. Hana Eshetu\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003efor review and comments of the manuscript during manuscript preparation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eDebre Berhan University, Asrat Woldeyes Health Science Campus, Department of Anesthesia lecturer, Debre Berhan, Ethiopia\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eAddis Ababa University, College of Medicine, School of Anesthesia, Department of Anesthesia Assistant professor and lecturer , Addis Ababa, Ethiopia\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWillett K, HAl-Khateeb R, Kotnis O, Bouamra F. Lecky Risk of mortality: the relationship with associated injuries and fracture treatment methods in patients with unilateral or bilateral femoral shaft fractures. J Trauma. 2010;69:405.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGurkan I, Wenz JF. Perioperative infection control: an update for patient safety in orthopaedic surgery. Orthopedics. 2006;29:329\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME. Pollak External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma. 2000;48:613\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNordt SP, Clark RF. Midazolam: a review of therapeutic uses and toxicity. J Emerg Med. 1997;15(3):357\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNucera E, Aruanno A, Buonomo A, Parrinello G, Rizzi A. Hypersensitivity reaction to midazolam: a case of 4 Case Reports in Anesthesiology cardio-respiratory failure, \u003cem\u003eAdvances in Dermatology and\u003c/em\u003e A\u003cem\u003ellergology\u003c/em\u003e, vol. 37, no. 6, pp. 1012\u0026ndash;1013, 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarrell B, Carrell WB. Fractures in the neck of the femur in children with particular reference to aseptic necrosis. JBJS. 1941;23(2):225\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePowell HDW. Simultaneous bilateral fractures of the neck of the femur. J Bone Joint Surg Br. 1960;42\u0026ndash;B(2):236\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1302/0301-620X.42B2.236\u003c/span\u003e\u003cspan address=\"10.1302/0301-620X.42B2.236\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDhar D. 2013. Bilateral traumatic fracture of neck of femur in a child: a case report. \u003cem\u003eMalaysian Orthopaedic Journal\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(2), p.34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWood RJ, White SM. Anaesthesia for 1131 patients undergoing proximal femoral fracture repair: a retrospective, observational study of effects on blood pressure, fluid administration and perioperative anaemia. Anaesthesia. 2011;66(11):1017\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeidel R, Barbakow E, Schulz-Drost S. 2021. Surgical treatment of proximal femoral fractures in high-risk geriatric patients under peripheral regional anesthesia: A prospective feasibility study. An\u0026auml;sthesist, \u003cem\u003e70\u003c/em\u003e(12).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParker MJ, Handoll HH, Griffiths R. 2004. Anaesthesia for hip fracture surgery in adults. \u003cem\u003eCochrane Database of Systematic Reviews\u003c/em\u003e, (4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang YY, Hui CK, Lau NC, Ng YT, Lin TY, Chen CH, Wang YC, Tang HC, Chen DWC, Chang CW. 2023. Total intravenous anesthesia for geriatric hip fracture with severe systemic disease. Eur J Trauma Emerg Surg, pp.1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen DX, Yang L, Ding L, Li SY, Qi YN, Li Q. 2019. Perioperative outcomes in geriatric patients undergoing hip fracture surgery with different anesthesia techniques: A systematic review and meta-analysis. Medicine, \u003cem\u003e98\u003c/em\u003e(49).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOllerton JE, Parr MJA, Harrison K, Hanrahan B, Sugrue M. 2006. Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department\u0026mdash;a systematic review. \u003cem\u003eEmergency Medicine Journal: EMJ\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(1), p.3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeschino A, Devitt JH, Koch JP, Szalai JP, Schwartz ML. The safety of awake tracheal intubation in cervical spine injury. Can J Anaesth. 1992;39:114\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakris A, Gkliatis E, Diakomi M, Karmaniolou I, Mela A. Delayed spinal epidural hematoma following spinal anesthesia, far from needle puncture site. Spinal Cord. 2014;52(1):S14\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDomenicucci M, Mancarella C, Santoro G, Dugoni DE, Ramieri A, Arezzo MF, Missori P. Spinal epidural hematomas: personal experience and literature review of more than 1000 cases. J Neurosurgery: Spine. 2017;27(2):198\u0026ndash;208.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Bilateral femur shaft fracture, anesthetic management, aged, tibiofibular, sign nail, cervical spine injury, hematoma, road traffic accident","lastPublishedDoi":"10.21203/rs.3.rs-3946339/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3946339/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePreoperative evaluation by an anesthetist must be performed since 70% of patients with a femur fracture will have an American Society of Anesthesiologists (ASA) score of III to IV. Although they occur rarely between 1 and 7%, bilateral femur fractures are linked to significant morbidity and mortality. Previous reports have described anesthetic management for aged patients who have bilateral femur fracture is difficult and needs team and increased perioperative complications. This case emphasizes the necessity to prepare adequately and improve knowledge and awareness of anesthetic management of patients for bilateral femur fracture and tibiofibular fracture for aged patients and needs multidisciplinary team to cooperate and increase the positive outcome of the patients. Patients with these conditions may present with various sign and symptoms that complicate the administration of anesthesia. Decisions regarding when to operate either before resuscitation or after the patient is resuscitated are one area of concern and consider preserving organ damage from secondary complications and maintain hemodynamic stability to ensure the anesthesia management is optimal and to increase the good outcomes of the patient.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCase report\u003c/b\u003e: A 50 year old male presented with bilateral femur shaft fracture and left tibiofibular fracture following road traffic accident and was planned for bilateral sign nail and left tibiofibular sign. Patient has cervical spine injury and epidural hematoma. Patient has undergone general anesthesia with endotracheal tube.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConclusion\u003c/b\u003e: We present a successful anesthetic management of patients who had bilateral femur fracture and left tibiofibular fracture with cervical spine injury and epidural hematoma. We emphasize the risk of neurological injury while extending the neck during laryngoscopy for tracheal intubation due to cervical spine injuries and we preferred to general anesthesia over spinal anesthesia due to contraindicated for spinal anesthesia in these patients. A detailed pre anesthetic evaluation and multidisciplinary approach as well as planning is utmost important and the anesthetic technique has to be individualized based on the patients anatomical characteristics and associated co-morbidities.\u003c/p\u003e","manuscriptTitle":"Anesthesia management of bilateral femur shaft fracture and left tibiofibular fracture for bilateral sign nail and tibiofibular sign with cervical spine injury and epidural hematoma: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-28 14:15:09","doi":"10.21203/rs.3.rs-3946339/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"64bee9b7-6a20-43bf-9c6b-84d945fe5fcd","owner":[],"postedDate":"February 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-12T09:14:15+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-28 14:15:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3946339","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3946339","identity":"rs-3946339","version":["v1"]},"buildId":"zQwnuV7TCBrMSSSToR1PI","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}