Hand Surgery Source

NAIL GUN INJURIES

Introduction

Although nail gun injuries have been reported to occur at various sites throughout the body, they most commonly affect the hand. These injuries have been fairly common since the industrial nail gun was introduced in 1959, and they usually result from accidental discharge or improper handling of the tool. The radial aspect of the nondominant hand is most susceptible to nail gun injuries because it is typically used to secure the object being nailed, and isolated damage to soft tissues occurs more frequently than structural damage. Conservative treatment includes nonsurgical nail extraction combined with debridement and a course of antibiotics. This treatment is often sufficient for injuries caused by small smooth nails with minimal contamination and no major structural damage.   Surgical exploration and extraction—with surgical debridement and irrigation—is likely to be necessary for more complicated cases,1,2 especially if symptoms or signs suggest involvement of nerves, arteries or joints.  Barbed nails also necesstiate surgical extraction in order to prevent further tissue damage during nail removal.

Pathophysiology

  • In most hand-related nail gun injuries, the radial aspect of the nondominant hand is used to grip or steady the structures being nailed and then inadvertently crosses the nail’s line of fire. Accidental discharge, careless handling of equipment, overpenetration of structures by the nail, ricochet or shattering of the nail, or structural unsoundness of the receiving material can all cause a mishap that results in a nail gun injury to the hand
    • If the nail fractures bone, resulting fragments can act as secondary missiles and further increase trauma to tissues2
    • Nail heads can remove skin or clothing and drive these foreign materials into the wound during the injury.  The entry wound may be further contaminated from nearby substances like oil, adhesives, paper, or plastics; this contamination from foreign bodies, combined devitalized tissue can all increase the risk for wound infection1,3
    • Copper wire fragments that join nails together can also shear off the strip as the nail exits the gun and remain attached to it; this will create a sharp “barb” that can further compound the injury and complicate the process of nail removal2

Related Anatomy

  • Nail gun injuries to the hand are generally classified as: direct bony injury, isolated soft tissue injury, or injury to joint, tendon, or nerve
    • Although the hand has an intricate and complex anatomy, most nail gun injuries only result in isolated soft tissue damage2
    • Direct bony injuries to the phalanges, metacarpals, carpus, radius, and ulna, as well as penetrating injuries to interphalangeal (IP) and radiocarpal joints have all been observed3

Incidence and Related Conditions

  • In residential carpentry, nail gun injuries account for about 14% of all injuries, with more than half of these involving penetrating trauma to the hand or fingers4
  • From 2001–2005, occupational pneumatic nail gun usage resulted in 22,000 annual Emergency Department visits per year in the United States, with approximately two-thirds of these injuries affecting the upper extremities, hand, and fingers5
ICD-10 Codes

NAIL GUN INJURIES

Diagnostic Guide Name

NAIL GUN INJURIES

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS SINGLE CODE ONLY LEFT RIGHT BILATERAL (If Available)
NAIL GUN INJURY - FINGER, w/FOREIGN BODY, w/o DAMAGE TO NAIL        
- INDEX   S61.241_ S61.240_  
- MIDDLE   S61.243_ S61.242_  
- RING   S61.245_ S61.244_  
- LITTLE   S61.247_ S61.246_  
- THUMB   S61.042_ S61.041_  
NAIL GUN INJURY - FINGER, w/FOREIGN BODY, w/DAMAGE TO NAIL        
- INDEX   S61.341_ S61.340_  
- MIDDLE   S61.343_ S61.342_  
- RING   S61.345_ S61.344_  
- LITTLE   S61.247_ S61.346_  
- THUMB   S61.142_ S61.141_  
NAIL GUN INJURY/PUNCTURE WOUND - w/FOREIGN BODY        
- HAND   S61.442_ S61.441_  
- WRIST   S61.542_ S61.541_  
- FOREARM   S51.842_ S51.841_  

Instructions (ICD 10 CM 2020, U.S. Version)

THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S51 AND S61
A - Initial Encounter
D - Subsequent Routine Healing
S - Sequela

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Clinical Examples of Serious Nail Gun Hand Injuries
  • Nail Gun Injury Right Dorsal Proximal Hand. Head of nail at arrow
    Nail Gun Injury Right Dorsal Proximal Hand. Head of nail at arrow
  • Nail Gun Injury base of left thumb
    Nail Gun Injury base of left thumb
  • Nail Gun Injury Right Wrist DRUJ
    Nail Gun Injury Right Wrist DRUJ
  • Nail Gun Injury Right long finger. First Responders had to cut the fence post and bring it with the patient
    Nail Gun Injury Right long finger. First Responders had to cut the fence post and bring it with the patient
  • Nail Gun Injury to base of left index finger
    Nail Gun Injury to base of left index finger
Symptoms
History of nail gun injury
Pain and swelling
Paresthesias
Decreased range of motion (ROM)
Typical History

The typical patient is a 32-year-old, right-handed, male construction worker. While working on the construction of a house, he accidentally discharged a pneumatic nail gun into the index and middle fingers of his left hand. He was trying to secure the 2x4 with these fingers as the nail gun discharged.  After the incident, the man experienced sudden severe pain because hid middle finger was nailed to the 2x4 stud. The patients helper separated the portion of the stud attached to the patient from the rest of the wooden stud. The patient with the attached nail and wood was then taken immediately to the emergency room for appropriate evaluation and surgical treatment.2,6

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
X-rays of Serious Nail Gun Hand Injuries
  • Nail Gun Injury X-ray Hand. Note incidental S-L gap.
    Nail Gun Injury X-ray Hand. Note incidental S-L gap.
  • Nail Gun Injury X-ray Right Hand
    Nail Gun Injury X-ray Right Hand
  • Nail Gun Injury oblique X-ray Left Hand
    Nail Gun Injury oblique X-ray Left Hand
  • Nail Gun Injury lateral X-ray Left Hand
    Nail Gun Injury lateral X-ray Left Hand
  • Nail Gun Injury AP X-ray Right Wrist DRUJ
    Nail Gun Injury AP X-ray Right Wrist DRUJ
  • Nail Gun Injury AP X-ray Right Wrist DRUJ. Note barbs on nail.
    Nail Gun Injury AP X-ray Right Wrist DRUJ. Note barbs on nail.
  • Nail Gun Injury to base of left index finger. No obvious fracture
    Nail Gun Injury to base of left index finger. No obvious fracture
  • Nail Gun Injury to base of left index finger. Oblique X-ray suggests injury to MP joint and the radial collateral ligament.
    Nail Gun Injury to base of left index finger. Oblique X-ray suggests injury to MP joint and the radial collateral ligament.
Treatment Options
Treatment Goals
  • Remove the nail without further damaging vital tissues.
  • Minimize the pain of extraction.
  • Minimize the risk of infection.
Conservative
  • Except for small smooth nails without barbs in a superficial locations,  nails should probably be removed in an OR by a hand surgeon.
  • Treatment for nail gun injuries adheres to standard principles of wound management. When there is minimal contamination and no neurovascular, tendon, or intra-articular injury and the patient has removed the nail before presentation the a conservative approach is typically recommended1,2
  • Nail extraction
    • The nail should be left in place until the clinical and radiographic evaluation is completed
    • In most cases, the head of the nail should be removed at the level of the entrance wound, and then the nail should be withdrawn slowly, in an antegrade direction, through the exit wound
    • The presence or suspected presence of barbs requires special consideration during extraction, and may warrant surgical exploration so that vital structures like nerves can be protected during extraction.
    • Nail size should not influence the technique of nail extraction or local wound care
  • Antibiotics
    • Oral or IV antibiotics may be appropriate, depending on the type of injury and resultant treatment
    • Cephalosporin
      • A short course of an oral 1st-generation cephalosporin is commonly recommended for noncomplicated cases3
    • Judicious use of antistaphylococcal and antipseudomonal antibiotics for 5-7 days is also recommended when surgical exploration is performed1
  • Nonsurgical reduction and immobilization
    • May be appropriate for stable fractures without substantial bone loss or contamination1
  • Limited debridement of local skin edges without primary closure can be used for superficial injuries.
Operative
  • Surgical exploration and nail extraction
    • Is necessary if there is a high level of contamination, insensate digit, devitalized tissue, neurovascular deficit, tendon injury, unstable fracture, or intra-articular involvement.2  Exploration ls also indicated if the nail head has entered deep into the subcutaneous tissues, which limits safe nail head removal1
    • Allows for appropriate identification and treatment of all concomitant injuries and helps prevent iatrogenic injuries
    • Particular care must be taken for presence of barbs
      • Open exploration and extraction of the barb under direct vision will help avoid secondary tissue damage
      • If an exit wound is not present, careful radiographic evaluation for barbs should dictate the direction of nail extraction since retrograde nail removal can deploy barbs and cause further soft tissue damage
      • Nail barbs deep to the subcutaneous tissues may necessitate extracting the nail antegrade through a surgically created exit wound
      • Although barbless nails can theoretically be removed in retrograde fashion, this should be performed with caution because barbs are not always visible on X-ray films1
    • Wounds may be left open or closed depending upon the extent and nature of the injury, and level of contamination2
  • Surgical debridement and/or irrigation
    • Is always indicated for cases with grossly contaminated wounds, neurovascular compromise, or clear penetration of a joint3  The wound and surrounding soft tissue should be thoroughly irrigated with normal saline, with or without antimicrobial agents2
    • Is essential to adequately debride nonviable tissues and remove all debris1
Treatment Photos and Diagrams
Operative Treatment of Nail Gun Injury involving Ulnar Artery and Nerve
  • Nail Gun Injury right palmar wrist DRUJ. Note (1) ulnar artery; (2) Ulnar nerve and imagine damage that barbs could cause if nail pulled out too aggressively.
    Nail Gun Injury right palmar wrist DRUJ. Note (1) ulnar artery; (2) Ulnar nerve and imagine damage that barbs could cause if nail pulled out too aggressively.
  • Nail Gun Injury to base of left index finger. Sterile bolt cutter used to remove end of the nail (arrow) be surgical open extraction.
    Nail Gun Injury to base of left index finger. Sterile bolt cutter used to remove end of the nail (arrow) be surgical open extraction.
Hand Therapy
  • May be recommended to recover hand function after nail extraction
Complications
  • Infection
  • Stiffness
  • Nerve injuries such as numbness, motor deficits paresthesias or other nerve injury
  • Complex Regional Pain Syndrome
  • Vascular injury
Outcomes
  • One study demonstrated that surgical exploration, nail removal, and debridement, along with IV antibiotics is considered a safe and short procedure that allows for a thorough assessment of the injury and appropriate repair. This was associated with minimal risk for infection or other complications7
Key Educational Points
  • There is no consensus concerning the treatment strategy for injuries with joint involvement, with some experts proposing that surgeons should open the joint for debridement and irrigation in cases with clear joint penetration or suspicion of joint penetration3
  • The use of framing nail guns—which discharge larger nails than other nail guns—has been continuing to rise in residential construction.  This increase is one factor behind the currently high risk for nail gun injuries in the trade8
  • Although neurovascular injuries resulting from nail guns are uncommon, the nail may be in close proximity to a neurovascular structure, which underscores the importance of thorough understanding of the mechanism of injury to avoid iatrogenic injury during tsurgical removal2
  • It is crucial for healthcare providers to understand and educate patients on the prevention mechanics of nail gun injuries, be aware of appropriate evaluation and indications for surgical management versus conservative management, while also recognizing potential pitfalls associated with each treatment alternative.2
References

Cited

  1. Rhee PC, Fox TJ, Kakar S. Nail gun injuries to the hand. J Hand Surg Am 2013;38(6):1242-6. PMID: 23541853
  2. Pierpont YN, Pappas-Politis E, Naidu DK, et al. Nail-gun injuries to the hand. Eplasty 2008;8:e52. PMID: 19079574
  3. Boya H, Uzun B. Hand injury with a nail gun: a case report with literature review. Acta Orthop Traumatol Turc 2015;49(3):334-7. PMID: 26200416
  4. Lipscomb HJ, Dement JM, Nolan J, et al. Nail gun injuries in residential carpentry: lessons from active injury surveillance. Inj Prev 2003;9(1):20-4. PMID: 12642553
  5. CDC. Nail-gun injuries treated in emergency departments—United States, 2001-2005. MMWR 2007;56(14):329-32. PMID: 17431377
  6. Hussey K, Knox D, Lambah A, et al. Nail gun injuries to the hand. J Trauma 2008;64(1):170-3. PMID: 18188117
  7. Ling SN, Ong NC, North JB. Eighty-seven cases of a nail gun injury to the extremity. Emerg Med Australas 2013;25(6):603-7. PMID: 24308618
  8. Lowe BD, Albers J, Hudock SD. A Biomechanical Assessment of Hand/Arm Force with Pneumatic Nail Gun Actuation Systems. Int J Ind Ergon 2014;44(5):715-722. PMID: 26321780

New Article

  • Boya H, Uzun B. Hand injury with a nail gun: a case report with literature review. Acta Orthop Traumatol Turc 2015;49(3):334-7. PMID: 26200416

Review

  • Rhee PC, Fox TJ, Kakar S. Nail gun injuries to the hand. J Hand Surg Am 2013;38(6):1242-6. PMID: 23541853

Classics

  1. Childs SA. Nail gun injury. Orthop Nurs 1991;10(6):15-8. PMID: 1762823
  2. Van Demark RE Jr, Van Demark RE Sr. Nailgun injuries of the hand. J Orthop Trauma 1993;7(6):506-9. PMID: 8308601