We compared a static extension orthosis with percutaneous pinning of the distal interphalangeal joint (DIPJ) for treatment of closed mallet injuries. After receiving counsel about treatment options, 44 patients (25 women and 19 men; mean age, 57 years) freely chose orthosis and 18 patients (5 women and 13 men; mean age, 51 years) chose pinning. Both the extension orthosis and the pin remained in place for 6 weeks; the pin then was removed, and the care in both groups was transitioned to nighttime orthosis use for an additional 6 weeks. The patients in the pin group were allowed to immediately resume unrestricted activity postoperatively. The mean follow-up was 32 months in the orthosis group and 19 months in the pin group. Final residual extensor lag was better in the pin group (5 vs 10 degrees, P = 0.048). Improvement between the groups was in favor of percutaneous pinning (36 vs 17 degrees, P = 0.001). No correlation was seen between time to treatment (≤14 vs >14 days from injury) and final extensor lag in either group (P = 0.85). The final mean DIPJ flexion was 53 degrees for orthosis and 46 degrees for pinning. Among the patients, 93% of the orthosis group and 100% of the pin group said that they would choose the same treatment again. Both groups had a mean of 5 hand therapy visits during treatment. Two complications occurred in the orthosis group (5%) and 3 (17%) occurred in the pin group. Extension orthotics and pinning are both well-tolerated, effective treatments of mallet injury. The techniques produce satisfactory correction of extensor lag and have high patient satisfaction. Pinning allows better correction of DIPJ extensor lag and results in a smaller degree of final extensor lag. Pinning is more expensive and may result in more DIPJ stiffness (ie, loss of active flexion), but it may be justified in certain patients (eg, medical professionals, food service workers) who would have difficulty working with an orthosis.