the  stubbed toe is a common innocuous injury , usually sustained barefoot , which can result in a wide range of injuries including nail bed lacerations , fractures of the distal phalanx and , uncommonly , bony or soft tissue mallet injuries .
the mainstay of management of simple fractures and nail bed injuries is usually non - operative , with good long - term function and little or no morbidity .
mallet fingers are common injuries with well - established treatments depending on the presence or absence of a fracture or joint subluxation . however , similar injuries to the hallux are rare with only a handful of single case report in the literature [ 37 ] .
the rarity of these injuries likely relates to the relative sizes of the digits and tendons and the protection offered by footwear .
owing to their relative rarity , there is no consensus as to the optimum treatment which ranged from non - operative treatment in a rigid soled shoe , closed reduction and stabilization with kirschner wires or open repair and reattachment of the tendon with suture anchors .
failure to recognize and treat these injuries can lead to extensor lag of the hallux , which carries some morbidity .
a 13-year - old girl injured her left great toe while running downstairs barefoot , incurring a forced plantar flexion injury .
there was pain , swelling and bruising to the hallux , but she was able to weight bear .
she noted a progressive drooping of the hallux over the following 3 weeks and presented to the trauma clinic via her gp . on examination , she had a swelling overlying the interphalangeal joint ( ipj ) of the hallux , which was held in 20 of plantar flexion , and she was unable to actively dorsiflex at the ipj .
plain radiographs showed no bony injuries , but the ipj was subluxed in a plantar - flexed position ( fig .  1 ) .
an urgent ultrasound scan confirmed a full thickness rupture of the extensor hallucis longus ( ehl ) tendon at its insertion into the distal phalanx and evidence of a healing tear to the dorsal joint capsule ( fig .  2 ) . 

plain radiograph showing plantar - flexed hallux ipj . ultrasound image showing ruptured ipj capsule and avulsed ehl tendon . under general anaesthesia
, an l - shaped incision was made to avoid the dorsomedial sensory nerve and avoid injury to the germinal matrix of the nail .
the ehl tendon was found to be completely ruptured from the distal phalanx and had retracted back towards the mtpj .
the tendon end was debrided back to healthy tissue and was secured back to the distal phalanx using a mitek anchor and a non - absorbable suture in a modified krakow technique .
the ipj was stabilized with a 1.2-mm kirschner wire ( figs  35 ) . 

figure  4:operative photograph showing transfixion of the ipj with a k - wire and insertion of a mitek anchor into the distal phalanx . 

operative photograph showing transfixion of the ipj with a k - wire and insertion of a mitek anchor into the distal phalanx .
the k - wire was removed 4 weeks postoperatively and she was placed into a thermoplastic extension splint for a further 4 weeks , allowed to weight bear normally in shoes and undertake a passive range of movement exercises with physiotherapy . at this stage , she had good power of dorsiflexion , but limited plantar flexion due to stiffness .
at the point of discharge , 6 months following surgery , she had regained a full range of movement compared with the contralateral side , full power of plantar flexion and dorsiflexion , and had returned to normal function .
the earliest reports of  mallet hallux by rapoff in 1999 and saxby et al in 2001 advocated non - operative treatment with a rigid soled shoe and an extension splint , respectively [ 3 , 7 ] .
these cases were both middle - aged patients who had sustained bony mallet injuries and following treatment had stiff ipjs , but were asymptomatic with good function . more recently ,
three of these reports describe temporary stabilization with k - wires ( either to reduce and stabilize fracture fragments directly or to act as blocking wires ) [ 5 , 6 , 8 ] . in all of these cases ,
all report bony union within 58 weeks and full function at final follow - up .
however , only one of these patients ( who was 16 years old ) regained a full range of movement .
mallet hallux using bio - absorbable suture anchors and non - absorbable sutures , in combination with early mobilization of the joint .
they were concerned that popular k - wire transfixion was associated with a high degree of stiffness and the possibility of infection and wire breakage .
they showed that with this combination of treatment , both of their patients were able to get back to full function relatively sooner with no stiffness of the joint .
hallux mallet as the ehl tendon is larger than the extensor tendons involved in soft tissue mallet injuries of the fingers , meaning that the repair is of better quality . in our reported case , due to the chronicity of the rupture ( nearly 4 weeks at the time of surgery ) and degree of retraction of the ehl tendon , it was felt that the patient would benefit from the combined treatment with a suture anchor and k - wire transfixion .
following this combination of treatment , the patient has made a full functional recovery and achieved a full range of movement .
we feel that this reflects the strength of the reconstruction and relative protection that the k - wire affords in addition to a suture anchor , with relatively early ( 4 weeks ) passive movement . additionally , the only other patient to achieve a full range of movement following treatment was also a teenager ( despite having ipj transfixion ) , suggesting that , as with most injuries , the virtues of youth enable better recovery .
unstable bony and soft tissue mallet injuries of the hallux are uncommon . in this more chronic case in a younger patient with significant retraction of the tendon , we advocate open reconstruction with combined suture anchor repair and k - wire transfixion , with a return to normal functional outcomes and a range of movement .
 we describe a case of a delayed presentation of a traumatic soft tissue mallet injury to the distal phalanx of the hallux in a teenager . 
 reports of this rare injury are sparse and there is no consensus in their treatment . 
 this injury was treated with open repair of the tendon using a mitek suture anchor , and stabilization with a 1.2-mm k - wire and extension splinting for 8 weeks . following this treatment , she regained full power and a range of movement compared with the contralateral side , and achieved full function . 
 we advocate surgical reconstruction of these injuries with suture anchors and stabilization of the interphalangeal joint . 