Acute hand compartment syndrome is a potentially devastating condition a hand surgeon may be called on to evaluate and treat. This pathophysiologic cascade of events that begins with an inciting event progresses to increased intracompartmental pressure, tissue necrosis, and resultant morbidity and potentially mortality. Many patients present with an altered sensorium, making the diagnosis challenging, requiring the clinician to rely on clinical findings and intracompartmental pressure measurements. The timing to definitive treatment with complete decompressive fasciotomies is critical to optimize patient outcomes. The goals of treatment are to prevent contracture, functional disability, and the loss of limb or life.