Nail Gun Injury

Penetrating Wound to the Chest • Xray of the Week

An 18 year-old presents with an injury to chest. What is the diagnosis?

Figure 1. AP and lateral chest x-ray showing foreign bodies. What is the diagnosis?

Figure 2. Annotated AP and lateral chest x-ray showing nail penetrating the right ventricle. Clip represents entry wound of the nail (red arrow). Mild enlargement of cardiac silhouette indicating pericardial effusion.

Figure 3. Commercial pneumatic nail gun. Safety release (blue arrow) must be fully depressed (in the direction of red arrow) for nail to be ejected.

Discussion

Workplace injuries due to pneumatic nail guns are common despite manufacture safety features. Those with increased risk are workers with limited experience using nail guns or with inadequate training on the use of the devices (1,2,3). Compared to injuries to the extremities, penetrating wounds to the heart are uncommon. Though rare, the morbidity and mortality of penetrating nail gun wounds to the heart are high (2). Due to the penetrating injury, blood can accumulate in the pericardial sac. The hemopericardiun can lead to cardiac tamponade which is an immediate life-threatening situation in addition to the damage done to the heart by the nail. Surgical approaches to repair cardiac injuries for penetrating nail gun injuries include sternotomy or anterolateral thoracotomy. A pericardiocentesis may be necessary to stabilize the patient before surgery can be performed.

Due to the safety features of nail guns and the difficulty of accidentally shooting one’s self in the chest, homicidal or suicidal intent should be considered (4), especially if the nail is unbent, which indicates the wound was not a result of a ricochet (5).

References:

1. Beaver, A. C., & Cheatham, M. L. (1999). Life-threatening nail gun injuries. The American surgeon, 65(12), 1113. https://www.ncbi.nlm.nih.gov/pubmed/10597056

2. Chirumamilla, V., Prabhakaran, K., Patrizio, P., Savino, J. A., Marini, C. P., & Zoha, Z. (2016). Pericardiocentesis followed by thoracotomy and repair of penetrating cardiac injury caused by nail gun injury to the heart. International journal of surgery case reports, 23, 98-100. http://www.sciencedirect.com/science/article/pii/S2210261216300815

3. Lipscomb, H. J., Dement, J. M., Nolan, J., & Patterson, D. (2006). Nail gun injuries in apprentice carpenters: risk factors and control measures. American journal of industrial medicine, 49(7), 505-513.https://www.ncbi.nlm.nih.gov/pubmed/16758488

4. McCorkell, S. J., Harley, J. D., & Cummings, D. (1986). Nail-Gun Injuries: Accident, Homicide, or Suicide?. The American journal of forensic medicine and pathology, 7(3), 192-195. https://www.ncbi.nlm.nih.gov/pubmed/3788906

5. Nadesan, K, A Fatal Nail Gun Injury - An Unusual Ricochet? Medicine, Science and the Law. January 2000 http://journals.sagepub.com/doi/pdf/10.1177/002580240004000116

Christopher Williamson, MSMP

1st year medical student

Medical College of Georgia at Augusta University

Jayanth Keshavamurthy, MBBS

Assistant Professor of Radiology

Department of Radiology and Imaging

Medical College of Georgia at Augusta University

https://webapps.gru.edu/PROD/iflapi.viewfac?CGInetid=JKESHAVAMURTHY