Acute carpal tunnel syndrome is progressive compression of the median nerve, often caused by external trauma and associated with distal radius fractures. This compression causes nerve ischemia, damage that quickly shifts from reversible to irreversible. Symptoms include progressive median neurologic symptoms, pain out of proportion, and thenar weakness. Although infrequent, it is imperative that this is recognized and treated promptly with carpal tunnel release, often in conjunction with fracture fixation.