Acute compartment syndrome (ACS) is a serious complications, the diagnosis of which is often delayed due to the masking of symptoms and unusual presentations. ACS is a surgical emergency and definitive treatment being fasciotomy. We describe a case of a 21-year-old male with history of sustaining a blast injury alongwith loss of consciousness for 10 min following the injury and a nose bleed. On arrival at the hospital, his Glasgow Coma Scale was 15/15. He gave a history of regular alcohol consumption. There was no other significant medical history.The trauma protocol revealed fractures of the right medial malleolus with an open wound, left proximal tibia, and right zygomatic arch and abrasions to the face, hands, and legs. Computed tomography of the brain showed scalp hematoma and an otherwise normal study.The patient was posted for wound debridement and tension band wiring of the right medial malleolar fracture and planned for left proximal tibial fracture plating on a later date.An uneventful surgery was performed under subarachnoid block (SAB) with 0.5% bupivacaine heavy 12.5 mg intrathecally. The patient was agitated and restless in the postanesthetic care unit (PACU) 2½ h after the SAB. He was given routine pain medications which included opioids and nonsteroidal anti-inflammatory drugs. However, he continued to be restless and agitated even an hour later.The differential diagnoses considered at this point included pain due to the receding SAB, worsening of head injury, alcohol withdrawal, dysfunctional pulse oximetry probe (inability to get a good waveform as the limb was in a cast), and compartment syndrome.Detailed pain assessment including the intensity and the site, nature of the pain should be elicited periodically in cases with multiple fractures and injuries. Detailed and persistent questioning revealed pain to be arising from the left lower limb with the tibia fracture rather than the operated limb with the malleolar fracture and diagnosed to have an ACS, and an immediate fasciotomy was done.Central nervous system compromise and dysfunction can be an issue following head injury and in alcohol withdrawal. The progression of head injury and alcohol withdrawal could present as altered mental status, restlessness, and agitation. These factors could have been misconstrued, and the diagnosis of ACS could have been missed or delayed. Difficulties with sedation or pain management may be the only clinical indicator of ACS in these patients.[12] Pain is considered to be an unreliable symptom as it is subjective and variable. In many of the case reports reviewed, pain was present but ACS not considered for a period of time.[3] Pain is due to the ischemia to the muscles and nerves. Muscular damage begins as early as 2 h and is irreversible in 4–6 h. Nerves can withstand ischemia up to 6–8 h, and ischemic pain can develop as early as 2 h.[4]The patient was in the PACU and had constant care even late at night that enabled quick assessments and treatment.Vigilance, education, and high index of suspicion are the key to early detection and diagnosis of ACS that could result in favorable treatment and outcomes.[5] A case of ACS with multiple confounding factors could have been easily missed leading to disastrous complications. It is of surmount importance to keep in mind the likelihood of ACS in patients with these factors along with a tibial fracture who present with cognitive dysfunction instead of classical symptoms of ACS.[6]