Background: Individuals who spend long periods seated without repositioning are at increased risk of developing pressure ulcers over the ischial tuberosity. Aim: To describe the management of an ischial pressure injury using a hatchet flap. Objectives: To reduce wound-related morbidity, improve quality of life, and prevent recurrence of pressure injuries. Material: A 22-year-old male developed a Grade IV ischial pressure ulcer six months after sustaining paraplegia from a fall. Although his neurological status improved gradually, the ulcer persisted and became recurrently infected. Staged wound debridement and hatchet flap coverage were performed. Result: The flap healed uneventfully, and there was no recurrence after the patient resumed mobilization. Conclusion: The random-pattern hatchet flap is a reliable option for the management of pressure sores of limited size, with minimal complications.