[Case Report] Community Emergency Department Management of a Nail Gun Puncture Wound: A Case Report

 Source

·        McDermand D, Dovgalyuk JM. Cureus. 2025 Jul 13;17(7):e87831.
doi: 10.7759/cureus.87831

 

Case Presentation

·         Nail gun injury Is a common ED presentation, that in most cases can be managed without direct access to specialties such as hand surgery and plastic surgery.

·         A 51 y.o, right hand dominant male presented with nail gun injury to his left hand, with history of diabetes and septic bursitis, with complaints of local pain but no numbness or tingling.

o   Full but painful range of motion of all the digits.

o   Uptodate tetanus booster 2-3 years ago.

·         Initial vitals: 95 F temperature (oral), heart rate 75 bpm, blood pressure 167 / 107 mmHg, O2 saturation of 94% on ambient air.

·         A 3-inch nail puncturing his left palm, through the dorsal side, in between 2^nd and 3^rd metacarpals.

·         Normal digital ROM, intact neurovascular and normal radial pulse, and no active bleeding from the wound.

·         Radiograph of the left hand shows the nail going through the palm out the dorsal side between 2^nd and 3^rd metacarpal without any dislocation or fracture.

 

·         Prior to any attempts of nail removal, plastic surgeon was consulted, who, based on the absence of bone injuries or significant tissue damage on radiographs and stable patient, decided removal is to proceed with instructions.

o   Barbed end (head) of the screw (embedded in the palmar side) was cut with a wire cutter.

o   Lidocaine 1%  (without epinephrine) 10 cc was injected liberally into the tissues surrounding the puncture wound.

o   With the dorsum of the patient’s hand being the fulcrum (hand with plier on patient’s backhand to adjust the pulling to minimize risk of iatrogenic injury during extraction), the nail was pulled out with a plier from the dorsal aspect without difficulty, resulting in only minimal bleeding that is well controlled with pressure.

o   Followed by wound cleaning, generous irrigation with sterile saline, and bandaging to the wound.

o   Patient was discharged from ED with Keflex 500 mg BID (10 days) and tramadol 50 mg prn (8 tablets), and was instructed to return to ED when worsening (increased redness, pain, warmth, drainage), occurs, and an outpatient follow up in plastic surgery.

 

Discussion

·         Nail gun injuries are generally accidental, most commonly affecting the hands, which, despite the intricate anatomy of the hands, resulted in about 25% of cases that had significant damage (such as tendon injury, nerve injury, space violation).

o   Incidence of around 37,000 ED visits annually from 2001 – 2005.

·         Prior to simple removal, one must confirm significant injuries (soft tissue injury, nerve, vascular, and bony injuries) are absent.