Nail gun injury

Nail injuries are important causes of penetrating craniocerebral injuries. Theirs incidence is very low, but the injuries can be fatal. Since the nail gun was gradually popularized in 1959, the incidence of nail injuries has been increasing.

It is an extremely rare neurosurgical emergency. The most common cause of nail gun injury is work related accidents; other causes result from accidental firing of a nail gun, suicide attempts by firing nail guns into the brain, and bomb blasts containing pieces of nails.

Neurosurgical treatment performed by craniotomy still seems to be the safest one;

There are reports of complications such as subdural hematoma and intraparenchymal hemorrhages following the blind removal of foreign bodies leading to suggestions that all penetrating foreign bodies should be removed under direct vision ¹⁾.

A case of nail gun injury to superior sagittal sinus and review the literature of the past 60 years to find out what are the possible factors of nail gun injury and what are their respective ratios?

An 18-year-old male patient was accidentally injured in the head by the worker's nail gun, accompanied by scalp pain, no physical sensation disorder, and consciousness disorder. A computed tomography scan of his skull showed the penetrating site at the right frontal area, near the superior sagittal sinus. Seven days later, the patient underwent a successful surgery without neurological sequelae.

Wang et al. found that nail guns were the main cause of nail injuries, and other causes include occupational injury, violence, lack of supervision of young children (potential for domestic violence, and child abuse), mental illness, and suicide attempts. While paying attention to the anatomical location of trauma, clinicians should also think more about the possibility of injury so as to provide better help to patients in time ²⁾.

Bigder et al report a nail-gun Injury through the Spinal Canal ³⁾.

A 21-year-old male roofer presented to the emergency department after suffering an accidental, self-inflicted nail gun injury to the midline of his sacrum. The patient was neurologically intact and a computed tomography (CT) of the pelvis with rectal contrast noted the nail to be located midline within the spinal canal at the level of S3 without injury to the rectum. The patient was taken to the operating room for removal of the nail under general anesthesia and exploration of the wound, specifically looking for evidence of a dural tear, which was determined not to be present. The wound was closed primarily and the patient was given 24 hours of intravenous antibiotics followed by 2 weeks of oral antibiotics. At follow-up, the patient had returned to his roofing job full-time and there was no evidence of infection on examination or retained foreign bodies by radiograph.

On the basis of Stern et al. experience and a review of the literature, in terms of treating a nail gun injury to the sacrum we recommend the following: exploration in the operating room to investigate the possibility of a dural tear, thorough irrigation, and debridement, especially in the case of barbed nails, and consultation with general surgery to determine if there is any injury to intrapelvic contents before surgery. An infectious disease consultation postoperatively may also assist in proper selection and duration of antibiotic therapy ⁴⁾.

A 44-year-old man was admitted to emergency room for an incomplete cauda equina syndrome after trying to kill himself by means of a pneumatic nail gun. The nail had gone right through the third lumbar vertebra. Because of the stability of the fracture, orthopaedic surgery was not indicated. Neurological recovery was progressive. At 6 months, there was still a partial L5-S1 motor deficit on the left side but the patient could walk without crutches, and within an unlimited walking distance.

Initial imaging displayed a projectile trajectory focused on the spinal canal on level L3, which could have been considered as bad prognosis. The positive analytic and functional outcome correlates with the limited neurological tissue damage, probably explained by the ballistic properties of the projectile.

Apart from the influence of a possible surgical act, the neurological and functional prognosis of a traumatic cauda equina syndrome caused by a projectile also depends on its physical characteristics ⁵⁾

A 56-year-old male was admitted due to chest injury. On admission, he showed numbness of the hand & leg, left hemiparesis and hypalgesia. Physical examination disclosed three nails on the left anterior chest, but other wounds or nails were not found. Chest films showed three nails penetrating the lung without reaching the heart, but other nails were found by skull and neck films. One nail had penetrated the cervical canal at the C1 level through the posterolateral cervical region. Two other nails were demonstrated at the right temporal and the left frontal region, Computed tomography revealed no massive cerebral hemorrhage and cerebral angiography showed no extravasation and no passage through main vessels. Emergency surgery was performed uneventfully and the nails in the chest, neck and head were totally removed. He was discharged one month after surgery. Some injuries caused by a nail-gun have been reported in the world literature but in Japan this multiple injury case was the first reported. Since nail-gun injuries can cause multiple damage, systemic X-ray examination was very important ⁶⁾.

1: Wang AS, Zeng MH, Wang F. Successful Treatment of a Nail Gun Injury in Right Parietal Region and Superior Sagittal Sinus. J Craniofac Surg. 2021 Jun 1;32(4):1297-1301. doi: 10.1097/SCS.0000000000007214. PMID: 34111879.

2: Zhu RC, Yoshida MC, Kopp M, Lin N. Treatment of a self-inflicted intracranial nail gun injury. BMJ Case Rep. 2021 Jan 11;14(1):e237122. doi: 10.1136/bcr-2020-237122. PMID: 33431447; PMCID: PMC7802712.

3: Patchana T, Taka TM, Ghanchi H, Wiginton J 4th, Wacker M. Case Report: Projectile Into Right Frontal Lobe From a Nail Gun. Cureus. 2020 Jul 29;12(7):e9460. doi: 10.7759/cureus.9460. PMID: 32874792; PMCID: PMC7455395.

4: Yazar U. Penetrating craniocerebral nail gun injury in a child: a case report. Childs Nerv Syst. 2021 Apr;37(4):1345-1349. doi: 10.1007/s00381-020-04800-6. Epub 2020 Jul 15. PMID: 32671533.

5: Andereggen L, Widmer HR, Santo SD, Andres RH. Functional muscle strength recovery from nail gun injury to the primary motor cortex. Regen Med. 2020 May;15(5):1603-1609. doi: 10.2217/rme-2019-0146. Epub 2020 Jul 1. PMID: 32609065.

6: Yamamoto A, Umeda Y, Kamei Y, Suzuki H, Kondo C, Tashiro H. Penetrating nail- gun injury of the thoracic descending aorta. Acute Med Surg. 2020 Jun 19;7(1):e530. doi: 10.1002/ams2.530. PMID: 32577291; PMCID: PMC7305459.

7: Harrington BM, Gretschel A, Lombard C, Lonser RR, Vlok AJ. Complications, outcomes, and management strategies of non-missile penetrating head injuries. J Neurosurg. 2020 Jun 19:1-9. doi: 10.3171/2020.4.JNS20122. Epub ahead of print. PMID: 32559744.

8: Young M, Putty M, Finneran MM, Johnson R, Schaible K, Farhat H. Multidisciplinary Management of Low-velocity Nonmissile Penetrating Head Injuries. Cureus. 2020 Mar 24;12(3):e7388. doi: 10.7759/cureus.7388. PMID: 32337115; PMCID: PMC7179989.

9: Nussbaum ES, Graupman P, Patel PD. Repair of the superior sagittal sinus following penetrating intracranial injury caused by nail gun accident: case report and technical note. Br J Neurosurg. 2019 Jun 20:1-5. doi: 10.1080/02688697.2019.1630550. Epub ahead of print. PMID: 31220943.

10: Brzezicki G, Meyer TE, Madbak F, Widrich J, Jensen A. Nail Gun Injury and Endovascular Repair of Cervical Internal Carotid Artery. Cureus. 2019 Mar 12;11(3):e4237. doi: 10.7759/cureus.4237. PMID: 31131161; PMCID: PMC6516626.

11: Chen CW, Yang SC, Liu KT, Wu YH. Foreign body in the thoracic spine due to a nail gun penetrating injury: A case report. Medicine (Baltimore). 2018 Dec;97(52):e13870. doi: 10.1097/MD.0000000000013870. PMID: 30593192; PMCID: PMC6314768.

12: Wallace DJ, Sy C, Peitz G, Grandhi R. Management of non-missile penetrating spinal injury. Neurosurg Rev. 2019 Dec;42(4):791-798. doi: 10.1007/s10143-018-01057-1. Epub 2018 Dec 18. PMID: 30560517.

13: Pniel D, Withers TK. A case of multiple nail gun injuries to the head and one to the heart. Surg Neurol Int. 2018 Nov 1;9:221. doi: 10.4103/sni.sni_75_18. PMID: 30533268; PMCID: PMC6238325.

14: Wu R, Ye Y, Liu C, Yang C, Qin H. Management of Penetrating Brain Injury Caused by a Nail Gun: Three Case Reports and Literature Review. World Neurosurg. 2018 Apr;112:143-147. doi: 10.1016/j.wneu.2018.01.127. Epub 2018 Jan 31. PMID: 29410036.

15: Morita T, Maki Y, Yamada D, Ishibashi R, Chin M, Yamagata S. External Ventricular Drainage Preceding the Removal of a Nail from the Intracranial Space as a Safe Management Strategy for Predicted Secondary Intraventricular Hemorrhage. World Neurosurg. 2017 Oct;106:1056.e9-1056.e13. doi: 10.1016/j.wneu.2017.07.104. Epub 2017 Jul 26. PMID: 28755920.

16: Awori J, Wilkinson DA, Gemmete JJ, Thompson BG, Chaudhary N, Pandey AS. Penetrating Head Injury by a Nail Gun: Case Report, Review of the Literature, and Management Considerations. J Stroke Cerebrovasc Dis. 2017 Aug;26(8):e143-e149. doi: 10.1016/j.jstrokecerebrovasdis.2017.04.004. Epub 2017 May 24. PMID: 28551290.

17: Rennert RC, Steinberg JA, Sack J, Pannell JS, Khalessi AA. Ventricular Tract Hemorrhage Following Intracranial Nail Removal: Utility of Real-time Endovascular Assistance. Front Neurol. 2016 Jul 14;7:112. doi: 10.3389/fneur.2016.00112. PMID: 27471490; PMCID: PMC4943964.

18: Ferraz VR, Aguiar GB, Vitorino-Araujo JL, Badke GL, Veiga JC. Management of a Low-Energy Penetrating Brain Injury Caused by a Nail. Case Rep Neurol Med. 2016;2016:4371367. doi: 10.1155/2016/4371367. Epub 2016 Jun 26. PMID: 27429815; PMCID: PMC4939200.

19: Mielniczek P, Zieliński G, Koziarski A. Sposoby leczenia nietypowych obrażeń postrzałowych głowy–opisy przypadków [Treatment methods of atypical gunshot wounds to the head–case reports]. Pol Merkur Lekarski. 2016 May;40(239):318-24. Polish. PMID: 27234864.

20: Carnevale JA, Morrison JF, Choi DB, Klinge PM, Cosgrove GR, Oyelese AA. Self-inflicted nail-gun injury with cranial penetration and use of intraoperative computed tomography. Surg Neurol Int. 2016 May 6;7(Suppl 10):S259-62. doi: 10.4103/2152-7806.181980. PMID: 27213112; PMCID: PMC4866056.

21: Makoshi Z, AlKherayf F, Da Silva V, Lesiuk H. Nail gun injuries to the head with minimal neurological consequences: a case series. J Med Case Rep. 2016 Mar 16;10:58. doi: 10.1186/s13256-016-0839-1. PMID: 27080512; PMCID: PMC4832548.

22: Zyck S, Toshkezi G, Krishnamurthy S, Carter DA, Siddiqui A, Hazama A, Jayarao M, Chin L. Treatment of Penetrating Nonmissile Traumatic Brain Injury. Case Series and Review of the Literature. World Neurosurg. 2016 Jul;91:297-307. doi: 10.1016/j.wneu.2016.04.012. Epub 2016 Apr 9. PMID: 27072332.

23: Thawani JP, Lucas TH. Open traumatic brain injury by nail gun resulting in a persistent vegetative state. Neurology. 2016 Apr 5;86(14):1358-1359. doi: 10.1212/WNL.0000000000002549. PMID: 27044613; PMCID: PMC4826342.

24: Isaacs AM, Yuh SJ, Hurlbert RJ, Mitha AP. Penetrating intracranial nail-gun injury to the middle cerebral artery: A successful primary repair. Surg Neurol Int. 2015 Sep 28;6:152. doi: 10.4103/2152-7806.166168. PMID: 26500798; PMCID: PMC4596057.

25: Yuh SJ, Alaqeel A. Ten self-inflicted intracranial penetrating nail gun injuries. Neurosciences (Riyadh). 2015 Jul;20(3):267-70. doi: 10.17712/nsj.2015.3.20150088. PMID: 26166596; PMCID: PMC4710333.

26: Kaufman KR, Schineller TM, Tobia A, Schneider JA, Bagayogo IP. Hypersexuality after self-inflicted nail gun penetrating traumatic brain injury and neurosurgery: case analysis with literature review. Ann Clin Psychiatry. 2015 Feb;27(1):65-8. PMID: 25848667.

27: Bigder M, Zeiler F, Berrington N. Nail-gun Injury through the Spinal Canal. Can J Neurol Sci. 2015 May;42(3):203-4. doi: 10.1017/cjn.2015.17. Epub 2015 Mar 19. PMID: 25790179.

28: Jeon YH, Kim DM, Kim SH, Kim SW. Serious penetrating craniocerebral injury caused by a nail gun. J Korean Neurosurg Soc. 2014 Dec;56(6):537-9. doi: 10.3340/jkns.2014.56.6.537. Epub 2014 Dec 31. PMID: 25628820; PMCID: PMC4303736.

29: Kaufman KR, Schineller TM, Tobia A, Schneider JA, Bagayogo IP. Hypersexuality after self-inflicted nail gun penetrating traumatic brain injury and neurosurgery: case analysis with literature review. Ann Clin Psychiatry. 2014 Nov;26(4):e1-4. PMID: 25401719.

30: Oh HH, Kim Y, Park SC, Ha YS, Lee KC. Nail Gun Induced Open Head Injury: A Case Report. Korean J Neurotrauma. 2014 Oct;10(2):139-41. doi: 10.13004/kjnt.2014.10.2.139. Epub 2014 Oct 31. PMID: 27169051; PMCID: PMC4852606.

31: Kim TW, Shim YS, Oh SY, Hyun DK, Park HS, Kim EY. Head Injury by Pneumatic Nail Gun: A Case Report. Korean J Neurotrauma. 2014 Oct;10(2):137-8. doi: 10.13004/kjnt.2014.10.2.137. Epub 2014 Oct 31. PMID: 27169050; PMCID: PMC4852607.

32: Yu AY, Xu QH, Hu SL, Li F, Chen YJ, Yin Y, Zhu G, Lin JK, Feng H. Characteristics of a rat model of an open craniocerebral injury at simulated high altitude. Neuroreport. 2014 Nov 12;25(16):1272-80. doi: 10.1097/WNR.0000000000000259. PMID: 25191925; PMCID: PMC4222709.

33: Woodall MN, Alleyne CH Jr. Nail-gun head trauma: A comprehensive review of the literature. J Trauma Acute Care Surg. 2012 Oct;73(4):993-6. doi: 10.1097/TA.0b013e318256df41. PMID: 22835996.

34: Luo W, Liu H, Hao S, Zhang Y, Li J, Liu B. Penetrating brain injury caused by nail guns: two case reports and a review of the literature. Brain Inj. 2012;26(13-14):1756-62. doi: 10.3109/02699052.2012.700085. Epub 2012 Jul 23. PMID: 22823496.

35: Nathoo N, Sarkar A, Varma G, Mendel E. Nail-gun injury of the cervical spine: simple technique for removal of a barbed nail. J Neurosurg Spine. 2011 Jul;15(1):60-3. doi: 10.3171/2011.3.SPINE10718. Epub 2011 Apr 1. PMID: 21456893.

36: Lee CS, Park KH. Six nails in the head: multiple pneumatic nail gun head injury. Br J Neurosurg. 2010 Aug;24(4):493-4. doi: 10.3109/02688697.2010.504051. PMID: 20726759.

37: Englot DJ, Laurans MS, Abbed K, Bulsara KR. Removal of nail penetrating the basilar artery. Neurosurg Rev. 2010 Oct;33(4):501-4. doi: 10.1007/s10143-010-0268-3. Epub 2010 Jun 8. PMID: 20532583.

38: Adamo MA, Kenning T, Drazin D, Deshaies EM, Emrich JF. Nail gun injury to the craniocervical junction: a case report and review of the literature. J Trauma. 2010 Apr;68(4):E99-103. doi: 10.1097/TA.0b013e318169cd5f. PMID: 20386269.

39: Hiraishi T, Kawaguchi T, Kobayashi T, Tomikawa M, Ito Y, Fujii Y. Unstable stenosis of the internal carotid artery caused by a craniofacial nail-gun injury-case report-. Neurol Med Chir (Tokyo). 2009 Dec;49(12):590-3. doi: 10.2176/nmc.49.590. PMID: 20035134.

40: Ichinose N, Ikawa F, Ohbayashi N, Mitsuhara T, Abiko M, Inagawa T. [Multiple penetrating head injury by 8 nails: a case report]. No Shinkei Geka. 2009 Dec;37(12):1209-13. Japanese. PMID: 19999553.

41: Testerman GM, Dacks LM. Multiple self-inflicted nail gun head injury. South Med J. 2007 Jun;100(6):608-10. doi: 10.1097/SMJ.0b013e3180398e47. PMID: 17591316.

42: Selvanathan S, Goldschlager T, McMillen J, Campbell S. Penetrating craniocerebral injuries from nail-gun use. J Clin Neurosci. 2007 Jul;14(7):678-83. doi: 10.1016/j.jocn.2006.02.017. Epub 2007 Apr 23. PMID: 17452105.

43: Zazpe I, Vázquez A, Beaumont C, Bardón A, Azcona J, Gallo-Ruiz A, Portillo E. Heridas múltiples penetrantes intracraneales causadas por pistola de clavos: caso clínico [Multiple penetrating brain injuries caused by a nail gun: a case report]. Neurocirugia (Astur). 2006 Dec;17(6):544-9. Spanish. PMID: 17242844.

44: Panourias IG, Slatinopoulos VK, Arvanitis DL. Penetrating craniocerebral injury caused by a pneumatic nail gun: an unsuccessful attempt of suicide. Clin Neurol Neurosurg. 2006 Jul;108(5):490-2. doi: 10.1016/j.clineuro.2005.01.007. PMID: 16720223.

45: Litvack ZN, Hunt MA, Weinstein JS, West GA. Self-inflicted nail-gun injury with 12 cranial penetrations and associated cerebral trauma. Case report and review of the literature. J Neurosurg. 2006 May;104(5):828-34. doi: 10.3171/jns.2006.104.5.828. PMID: 16703892.

46: Sani S, Jobe KW, Byrne RW. Successful repair of an intracranial nail-gun injury involving the parietal region and the superior sagittal sinus. Case report. J Neurosurg. 2005 Sep;103(3):567-9. doi: 10.3171/jns.2005.103.3.0567. PMID: 16235693.

47: Spennato P, Bocchetti A, Mirone G, Savarese L, Squillante D, Rotondo M, Natale M. Double concentric craniotomy for a craniocerebral penetrating nail. Case report and technical note. Surg Neurol. 2005 Oct;64(4):368-71; discussion 371. doi: 10.1016/j.surneu.2004.12.003. PMID: 16231428.

48: Serlo W, Ashammakhi N, Törmälä P, Waris T. A new technique for cranial bone osteofixation: use of bioabsorbable tacks and plates to fix parietal bone split grafts used for reconstruction of a posttraumatic frontal bone defect. J Craniofac Surg. 2002 Mar;13(2):331-6. doi: 10.1097/00001665-200203000-00031. PMID: 12000899.

49: Jithoo R, Govender ST, Nathoo N. Penetrating nail gun injury of the head and chest with incidental pericallosal artery aneurysm. S Afr Med J. 2001 Apr;91(4):316-7. PMID: 11402901.

50: Inoha S, Suzuki S, Fukui M, Kuratomi Y, Nakao K, Miyazono M, Kamikaseda K. [A penetrating cranio-facial injury due to a nail-gun accident]. No Shinkei Geka. 1997 Jul;25(7):635-9. Japanese. PMID: 9218258.

51: Sakuta Y, Arai S. [Penetrating brain injury and traumatic aneurysm caused by a nail gun]. No Shinkei Geka. 1997 Apr;25(4):357-62. Japanese. PMID: 9125720.

52: Sasaoka Y, Kamada K, Matumoto M, Ueda Y, Iwasaka T, Hukushima T, Nishimura A, Mishima H, Inoue M. [Penetrating injury of the head, neck and chest by a nail-gun: a case report]. No Shinkei Geka. 1995 Dec;23(12):1099-104. Japanese. PMID: 8927217.

53: Tancioni F, Gaetani P, Pugliese R, Rodriguez y Baena R. Intracranial nail. A case report. J Neurosurg Sci. 1994 Dec;38(4):239-43. PMID: 7562030.

54: Rezai AR, Lee M, Kite C, Smyth D, Jafar JJ. Traumatic posterior cerebral artery aneurysm secondary to an intracranial nail: case report. Surg Neurol. 1994 Oct;42(4):312-5. doi: 10.1016/0090-3019(94)90399-9. PMID: 7974126.

55: Okada T, Futami K, Mukai H, Ikeda K, Yamashita J. Penetrating injury of the transverse sinus by a nail-gun–case report. Neurol Med Chir (Tokyo). 1993 Oct;33(10):703-5. doi: 10.2176/nmc.33.703. PMID: 7505899.