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Case: A 53-year-old man presented with a puncture wound to his right thumb, resulting in a horseshoe abscess, its infectious clinical picture muddled by dense paresthesias from the ensuing acute carpal tunnel syndrome. He was treated with irrigation and debridement of the thumb and small finger flexor tendon sheaths, carpal tunnel release, and bootlacing and dermal substitute application to the proximal forearm with eventual split-thickness skin grafting. Conclusion: Although a horseshoe abscess resulting in acute carpal tunnel syndrome is a rare entity unquantified in the literature, the treating orthopaedic surgeon should be aware of its association and initiate appropriate treatment accordingly. [ABSTRACT FROM AUTHOR]