Nail gun injuries, common in the construction industry, are usually puncture wounds on the hands and fingers, but sometimes they result in more serious injuries. Diagnosis is clinical; evaluation requires x-rays. Treatment is surgical.
Nail guns, which have replaced hammers in wood-frame construction, cause an estimated 37,000 emergency department visits each year; 68% of them are work-related.
Nail guns deliver nails at high velocity, which can penetrate soft tissue and bone. Most nail gun injuries involve the fingers and hand; however, injuries to the lower extremities, trunk, eyes, and head also occur. If the eyes are involved, vision may be lost. (See also National Institute for Occupational Safety and Health (NIOSH): Nail Gun Safety.)
In addition to the nail, other materials (eg, wire, fabric, paper, adhesive) can enter the wound during a nail gun injury and lead to infection.
Nail guns have been used in suicidal gestures.
Evaluation of Nail Gun Injuries
Sequential steps in evaluating nail gun injuries include the following:
Establishing hemostasis if needed
Identifying and treating damage to underlying structures
Patients typically present with the nail embedded in the wound. A compete evaluation of the distal neurologic, vascular, and tendinous components of the injured part is essential. In addition, plain x-rays are taken to see the general location of the nail, the type of nail, and underlying bone damage. Nails with structural barbs make removal more difficult and require exploration and removal in the operating room.
Wound evaluation requires good lighting. Magnification (eg, with magnifying glasses) can help, particularly for examiners with imperfect near-vision. Full wound evaluation may require probing or manipulation and thus local anesthesia, but sensory examination should precede use of a local anesthetic.
Associated injuries
Physicians should check for damage to underlying structures, including nerves, tendons, blood vessels, joints, and bones and for the presence of foreign bodies and penetration of body cavities (eg, peritoneum, thorax). Evaluation by a specialist may be required:
For nails embedded in bone or with neurovascular or tendinous injury: Evaluation by a hand surgeon (for hand involvement) or another relevant surgical specialist
For nail gun injuries to the eye: Evaluation by an ophthalmologist as soon as possible
Nail gun injuries to the head: Evaluation by a neurosurgeon as soon as possible
X-rays are taken. They help show nail location, the presence of any bone injury, and characteristics of the nail, which affect treatment; eg, nails with barbs are complicated to remove and require exploration and removal in an operating room.
Treatment of Nail Gun Injuries
Treating nail gun injuries involves
Removal of the nail
Wound care
Nails that are embedded in soft tissue and have no complicating injuries can be removed by firm traction (which requires local anesthesia), followed by wound cleansing, irrigation, and application of a sterile dressing (see also Lacerations). For all other nail gun injuries, the injury is explored and the nail is removed in the operating room.
Nail gun injuries are typically deep puncture injuries and should be allowed to heal by secondary intention rather than by primary intention (with immediate suturing). Tetanus prophylaxis is given when indicated.
Prevention of Nail Gun Injuries
Preventive efforts involve teaching workers the correct use of nail guns and the potentially devastating effects of nail gun injuries (see NIOSH: Nail Gun Safety—A Guide for Construction Contractors and Nailing Down the Need for Nail Gun Safety).
Key Points
Nail guns commonly cause injuries, often involving nerves, tendons, blood vessels, joints, bones, or penetration of body cavities.
Check for serious injuries with detailed examination, and take x-rays.
Use traction to remove only nails that are embedded in soft tissue and have no complicating injuries; otherwise, remove the nail in the operating room.
Allow most nail gun injuries to heal by secondary intention rather than trying to suture them.
