Background Compartment syndrome in the upper extremity is relatively uncommon compared to the lower extremity, and is most frequently associated with trauma. The treatment for acute compartment syndrome is emergent fasciotomy, however fasciotomy wounds are often unable to be primarily closed. When closure is not achievable, wounds are often reconstructed with a split thickness skin graft. In patients with tattoos, skin grafts can be particularly unsightly, and the disruption to the tattoo can be difficult and expensive to subsequently correct. Keystone perforator flaps are well described and commonly utilised local flaps. Their routine use in the volar forearm has been previously described for the purpose of closure of radial forearm free flap donor sites, however they have not been described for the purpose of closure of fasciotomy wounds. Case We report the case of a 35 year old otherwise well gentleman who presented post a motorbike accident (MBA) with an isolated closed, comminuted distal radius fracture and compartment syndrome. He underwent fasciotomy of his distal volar forearm, including carpal tunnel release, and concurrent internal fixation of his distal radius. The wound was unable to be closed directly, and skin grafting was declined due to the cosmetic impact on his extensive forearm tattoos. The defect was reconstructed with a fasciocutaneous keystone flap based on perforators from the ulanar artery, with only minor distortion of his tattoo, and overall good aesthetic outcome. Discussion The keystone flap is a simple and reliable flap that can be used as an alternative to skin grafting in forearm fasciotomy wounds, and can offer good aesthetic outcomes in patients with tattoos.