A 48-year-old man, who sustained an open tibial fracture in a motorcycle-car collision, presented with two small (approximately 2 cm) wounds on the proximal lower leg, which initially suggested limited superficial injury. Plain radiographs showed an AO/OTA 42C3 comminuted tibial shaft fracture. Emergency surgery with external fixation and wound irrigation was performed, followed by negative pressure wound therapy for severe swelling. Second- and third-look procedures revealed extensive deep muscle damage involving both the anterior and posterior compartments, necessitating staged debridement and resulting in a large 8×15 cm anterior soft-tissue defect with bone exposure. A free latissimus dorsi musculocutaneous flap was used for reconstruction and the area healed without complications, followed by split-thickness skin grafting. Despite the small bone defect, bone union was not achieved, and surgery for nonunion was required at 6 months post-injury. At final follow-up 12 months post-injury, satisfactory bone union and functional recovery were achieved. This case highlights that small open wounds may conceal extensive deep soft-tissue injury in high-energy comminuted fractures, emphasizing the importance of careful zone-of-injury assessment, adequate debridement, and appropriate staged reconstruction.
