A 40-year-old woman involved in a motor vehicle accident presented to the emergency room with signs and symptoms of acute left hand ischemia. The mechanism of injury consisted of a severe crushing component limited to a linear zone across the left hand metacarpals. After patient management, and compartment decompressions and stabilization of fractures, an ischemic state persisted that failed to improve after extensive vessel exploration and bathing in vasodilating solutions. Only after extensive peripheral sympathectomy was appropriate flow re-established to the hand. The need to employ periarterial sympathectomy in the acute trauma setting will occur infrequently, but is a valuable tool to have in mind when flow is not re-established after appropriate less invasive measures have failed.