- Email: [email protected]
Industrial nail-gun injuries: a review and case report
Injury, 6, 59-62
59
Industrial nail-gun injuries: a review and case report J. C. Lowry University Hospital of South Manchester Summary
CASE R E P O R T
A case of haemopneumothorax following penetration of the chest by a nail fired from a cartridge compression gun is presented. The literature covering nail-gun injuries is reviewed and the requirements for safety in design and use of the .tools are restated.
A 21-year-old bricklayer sustained an injury to the left side of the chest when a nail from a high-velocity tool, being used by a colleague, passed through a relatively flimsy casing, striking the patient while he was working out of sight on the other side. The projectile entered between the left fourth and fifth ribs anteriorly and passed directly through the chest to emerge lateral to the left scapula (Figs. 1 and 2). On examination in the casualty department, the patient was pale but not obviously shocked. The bloodpressure was 160/ll0mm. Hg and the pulse of good volume, regular at 100 per minute. There was a moderate left pneumothorax with a small effusion at the base. The trachea and mediastinum were deviated to the right.
SINCE the introduction of cartridge-powered nailguns in the construction industry some 13 years ago, several injuries caused by their use have been reported in the medical literature. This paper reports a case of h a e m o p n e u m o t h o r a x following such an injury, reviews the literature to demonstrate the wide range o f previously described accidents, and stresses the need for strict control of the use of such tools. Wider use of the low-velocity type of nail-gun is recommended. Cartridge tools fall into two categories: namely a high-velocity type and a captive plunger or lowvelocity type. The former is trigger operated and the latter by either a trigger or a hammer. The high-velocity tool works by the explosive power o f the cartridge acting directly on the nail or stud which is driven into the fixing surface (Harper, 1968). In the low-velocity tool there is a captive plunger which receives the force of the cartridge explosion and is driven down the barrel until it is arrested within the tool. The drive of the plunger reacts upon the nail which is pushed into the fixing surface, most of the cartridgeenergy being absorbed by the plunger. There is virtually no danger of firing through a fixing surface with the latter type and even if it should occur, for example through hardboard or plasterboard, the nail will travel at such a low velocity that, should it strike anyone, it is unlikely to produce a penetrating injury.
Fig. 1.---Showing entry wound above left nipple and site of intrapleural drain in second intercostal space, after removal.
60
Injury: the British Journal of Accident Surgery Vol. 5/No. 1
Over the following twelve hours increasing pallor and dyspnoea were observed as the left hemithorax filled with fluid and caused almost total collapse of the left lung (Fig. 3). The haemoglobin at this time was 10"9 g. and the packed cell volume was 31 per cent. A diagnosis of haemopneumothorax was made and an intrapleural drain in the form of a Malecot catheter was inserted through the second left intercostal space anteriorly. Two thousand ml. of bloodstained fluid were withdrawn and subsequently suction was applied for one minute every hour. A transfusion of 4 pints of whole blood was given and the drain was removed two days later.
including the left innominate artery, and embedded itself in the parenchyma of the upper lobe of the right lung. D e a t h was due to haemorrhage and mechanical obstruction to respiration. A tragic case which left the victim totally paralysed and requiring artificial ventilation was described by Spencer (1968). The patient who was holding an object to be fixed to a wall collapsed, apparently dead, after a nail-gun was fired by another worker. Resuscitation was begun at once as the accident occurred on a hospital site, and the heart restarted. The point of entry was in the region of the left zygomatic arch, with an exit wound above the right clavicle behind the
Fig. 2.--Showing exit wound lateral to left scapula.
Fig. 3.--Radiograph showing left hemithorax filled with fluid and lung almost totally collapsed.
Ten days later since the patient was pyrexial and there was still evidence of fluid and clotted haemothorax on the left with a moderate effusion on the right side, a thoracotomy was considered. However, on a conservative r6gime which included antibiotics, there was a distinct clinical and radiologieal improvement, with diminution of opacity and re-expansion of the left lung. He was allowed home 23 days after admission. At follow-up six weeks later there was residual pleural thickening on the left side but the chest was moving well and the lungs were fully expanded. The patient returned to work three and a half months after the accident.
sternomastoid. Injuries included irreparable spinal cord damage at the level of C.5 and a retropharyngeal haematoma. N o r t h (1970) reported three cases o f penetrating brain injury. The management followed the standard surgical principles of accurate localization, early d6bridement, removal of bone chips, foreign bodies, and associated haematoma. Two patients eventually made a full recovery, while the third died from the effects of an acute subdural haematoma. K a r l s t r 6 m and Kjeilman (1971) described the case o f a builder hit in the right temporal region with passage of the bolt through the floor of the m o u t h into the submental region after traversing the right orbit, maxillary sinus, and tongue. Operation was required for the removal of a subdural h a e m a t o m a and for decompression o f the orbit.
DISCUSSION Injuries associated with the use o f compression guns in industry vary widely in site and severity. Cragg (1967) reported a fatal case in which the nail entered the anterior chest wall of a young construction worker, perforated several vessels,
Lowry : Industrial Nail-gun Injuries
Allan (1970) reported a comminuted fracture of the angle of the mandible, a nail being found at operation entangled in the periosteum. Ewbank (1965) described another submandibular and cervical injury, but without bone damage. The foreign body in this case was removed from the soft tissues of the neck above the thyroid cartilage. Bala (1972) removed a nail five inches long via a palatal approach, the entry wound being in the left temporal region. A fracture of the clavicle was reported by Klenerman (1961), the patient having presented with a hard lump in the soft tissues of the supraclavicular fossa and an entry wound at the level of the left nipple in the anterior axillary line. Wilson (1962) described an unusual case of two men injured by the same nail. This passed through the left palm of the first, shattering two metacarpals, and then striking the second, in whom it tunnelled through the skin over the left pectoralis major, emerged at the anterior axillary fold, re-entered through the left deltoid, drilled a channel through the upper end of the humerus and finally emerged through the skin into the clothing. Exploration of the track revealed the plastic sleeve from the pin, which being radiolucent is often difficult to locate by radiography. Oldfield (1962) recorded a case in which the pin took a subcutaneous course in the chest and abdominal walls, and finally penetrated muscle in the left loin to come to rest in the left perinephric region. Other abdominal injuries have been reported by McMillan (1968), in whose patient the missile passed through the left kidney, spleen, stomach, diaphragm, and left ventricle. Karlstr6m and Kjellman (1971) reported a case in which a bolt entered the right flank, passed through the right lobe of the lever, right kidney, right spermatic and common iliac arteries, ricocheted off the pelvic wall to penetrate the intestinal mesentery, finally stopping retroperitoneally behind the left common iliac artery. The same authors described a further case in which there was a comminuted fracture of the radial diaphysis which required skin-grafting and internal fixation. Manning (1968), who saw four cases in five years, reported a nail embedded in the carpal bones, a facial laceration after a sliver of steel broke off a nail, and two cases of laceration from concrete shattered by impact. He also mentioned the fact that a safety-device on one type of gun could be retracted by hand, and therefore the use of the gun as a free-firing weapon was possible.
61
Neubert (1968) described four cases of eye injury in which masonry nails fractured when being driven in by an ordinary hammer and not by the nail-gun for which they were designed. Six cases were reported by H.M. Factory Inspectorate (1963) as typical of those reported each year, most of which indicated lack of training. It would therefore appear to be desirable for an approved training scheme to be instituted, following which the operator, having attained a satisfactory standard, would be licensed to operate the specific compression tools for which he had shown competence. Thus some degree of care in the use of these weapons could be ensured. The same report listed comprehensive rules for the use of the tools and gave advice on maintenance. Similar advice and information appeared in the British Standards Specification for Cartridge Operated Fixing Tools (1966). F r o m the nature and mode of causation of the injuries, it can be deduced that there are several desirable features that should be incorporated in design, if the frequency and severity of such accidents are to be reduced. These include:-1. The inability of the tool to be fired in free air. This is achieved by preventing the cartridge from being fired unless the spring-loaded barrel is pressed firmly and squarely against the fixing surface. 2. The incorporation of a non-removable shield to prevent possible ricochets or splintering of the material into which the nail is fired. 3. The prevention of firing of the gun unless the breech containing the cartridge is completely closed and locked. 4. The safe ejection of a ' misfired' cartridge. 5. The inability of a nail or bolt fired from such a tool to penetrate at high velocity a flimsy fixing surface. Several of these safeguards are contained in the British Standards Specification 4078 (1966). The last factor, however, cannot be adequately covered in the design of a high-velocity tool, and the training of the operator, both with regard to suitable surfaces on which to use the gun and the selection of the correct charge of cartridge, are of prime importance. The more widespread use of the lowvelocity tool would tend to overcome this danger, though the mechanical forces imposed on the fixing device during penetration are much greater. Improvement in nail quality and design must progress concurrently with that of tool design if accident hazards are to be reduced (Seghezzi, 1968).
62 Acknowledgements I s h o u l d like to t h a n k Mr. L. Turner, C o n s u l t a n t Surgeon, a n d Mr. W. K. Douglas, C o n s u l t a n t T h o r a c i c Surgeon, for permission to p u b l i s h this case a n d Dr. H. M c I n t y r e for advice in t h e p r e p a r a t i o n o f the paper. T h e illustrations are b y the D e p a r t m e n t o f Medical Illustration o f the University Hospital o f S o u t h M a n c h e s t e r for whose assistance I a m grateful.
REFERENCES
ALLAN, D. (1970), 'Compression gun injury ', Br. dent. J., 129, 135. BALA, S. (1972), personal communication. BRITISH STANDARDS INSTITUTE (1966), 'Specification for cartridge operated fixing tools ', Appendix A, 4078. CRAGG, J. (1967), ' Nail gun fatality ', Br. reed. J., 4, 784. EWBANK, R. L. (1965), ' Foreign body lodged in the neck; report of case ', J. oral Surg., 23, 657.
Injury: the British Journal of Accident Surgery Vol. 5/No. 1
HARPER, M. (1968), ' Play safe with cartridge tools ', Br. J. occup. Safety, 84, 409. H.M. FACTORY INSPECTORATE (1963), 'Accidents ', Ministry of Labour. KARLSTR()M, G., and KJELLMAN, T. (1971), ' Injuries caused by nail-gun accidents ', Acta chh'. scand., 137, 474. KLENERMAN, L. (1961), 'Industrial bullet wound ', Br. n, ed. J., 2, 1785. McMILLAN, I. K. R. (1968), 'Nail-gun accident ', Ibid., 1, 181. MANNING, D. P. (1968), 'Nail-gun accident', Ibid., 1, 18 I. NEUBERT, F. R. 0968), ' Nail-gun and masonry nail accidents ', Ibid. 1, 511. NORTH, J. B. (1970), ' Nail-gun injuries of the brain ', Med. J. Aust., 2, 183. OLDFIELD, M. C. (1962), 'Industrial bullet wound ', Br. reed. J., 1, 262. SEGHEZZI, H. D. (1968), ' A study of kinetic energy as a cause of accident hazards with power actuated tools ', Sichere Arbeit., 1, 5. SPENCER,G. T. (1968), ' Nail-gun accident ', Br. reed. J., 1, 181. WILSON, P. J. E. (1962), 'Industrial bullet wound ', Ibid., 1, 341.
Requests for reprints should be addressed to:--J. C. Lowry, Esq., M.B., Ch.B., B.D.S., F.D.S.R.C.S.(Eng.), M.R.C.S., L.R.C.P., 5 St. Andrew's Road, St. Anne's Park, Cheadle, Cheshire.
59
Industrial nail-gun injuries: a review and case report J. C. Lowry University Hospital of South Manchester Summary
CASE R E P O R T
A case of haemopneumothorax following penetration of the chest by a nail fired from a cartridge compression gun is presented. The literature covering nail-gun injuries is reviewed and the requirements for safety in design and use of the .tools are restated.
A 21-year-old bricklayer sustained an injury to the left side of the chest when a nail from a high-velocity tool, being used by a colleague, passed through a relatively flimsy casing, striking the patient while he was working out of sight on the other side. The projectile entered between the left fourth and fifth ribs anteriorly and passed directly through the chest to emerge lateral to the left scapula (Figs. 1 and 2). On examination in the casualty department, the patient was pale but not obviously shocked. The bloodpressure was 160/ll0mm. Hg and the pulse of good volume, regular at 100 per minute. There was a moderate left pneumothorax with a small effusion at the base. The trachea and mediastinum were deviated to the right.
SINCE the introduction of cartridge-powered nailguns in the construction industry some 13 years ago, several injuries caused by their use have been reported in the medical literature. This paper reports a case of h a e m o p n e u m o t h o r a x following such an injury, reviews the literature to demonstrate the wide range o f previously described accidents, and stresses the need for strict control of the use of such tools. Wider use of the low-velocity type of nail-gun is recommended. Cartridge tools fall into two categories: namely a high-velocity type and a captive plunger or lowvelocity type. The former is trigger operated and the latter by either a trigger or a hammer. The high-velocity tool works by the explosive power o f the cartridge acting directly on the nail or stud which is driven into the fixing surface (Harper, 1968). In the low-velocity tool there is a captive plunger which receives the force of the cartridge explosion and is driven down the barrel until it is arrested within the tool. The drive of the plunger reacts upon the nail which is pushed into the fixing surface, most of the cartridgeenergy being absorbed by the plunger. There is virtually no danger of firing through a fixing surface with the latter type and even if it should occur, for example through hardboard or plasterboard, the nail will travel at such a low velocity that, should it strike anyone, it is unlikely to produce a penetrating injury.
Fig. 1.---Showing entry wound above left nipple and site of intrapleural drain in second intercostal space, after removal.
60
Injury: the British Journal of Accident Surgery Vol. 5/No. 1
Over the following twelve hours increasing pallor and dyspnoea were observed as the left hemithorax filled with fluid and caused almost total collapse of the left lung (Fig. 3). The haemoglobin at this time was 10"9 g. and the packed cell volume was 31 per cent. A diagnosis of haemopneumothorax was made and an intrapleural drain in the form of a Malecot catheter was inserted through the second left intercostal space anteriorly. Two thousand ml. of bloodstained fluid were withdrawn and subsequently suction was applied for one minute every hour. A transfusion of 4 pints of whole blood was given and the drain was removed two days later.
including the left innominate artery, and embedded itself in the parenchyma of the upper lobe of the right lung. D e a t h was due to haemorrhage and mechanical obstruction to respiration. A tragic case which left the victim totally paralysed and requiring artificial ventilation was described by Spencer (1968). The patient who was holding an object to be fixed to a wall collapsed, apparently dead, after a nail-gun was fired by another worker. Resuscitation was begun at once as the accident occurred on a hospital site, and the heart restarted. The point of entry was in the region of the left zygomatic arch, with an exit wound above the right clavicle behind the
Fig. 2.--Showing exit wound lateral to left scapula.
Fig. 3.--Radiograph showing left hemithorax filled with fluid and lung almost totally collapsed.
Ten days later since the patient was pyrexial and there was still evidence of fluid and clotted haemothorax on the left with a moderate effusion on the right side, a thoracotomy was considered. However, on a conservative r6gime which included antibiotics, there was a distinct clinical and radiologieal improvement, with diminution of opacity and re-expansion of the left lung. He was allowed home 23 days after admission. At follow-up six weeks later there was residual pleural thickening on the left side but the chest was moving well and the lungs were fully expanded. The patient returned to work three and a half months after the accident.
sternomastoid. Injuries included irreparable spinal cord damage at the level of C.5 and a retropharyngeal haematoma. N o r t h (1970) reported three cases o f penetrating brain injury. The management followed the standard surgical principles of accurate localization, early d6bridement, removal of bone chips, foreign bodies, and associated haematoma. Two patients eventually made a full recovery, while the third died from the effects of an acute subdural haematoma. K a r l s t r 6 m and Kjeilman (1971) described the case o f a builder hit in the right temporal region with passage of the bolt through the floor of the m o u t h into the submental region after traversing the right orbit, maxillary sinus, and tongue. Operation was required for the removal of a subdural h a e m a t o m a and for decompression o f the orbit.
DISCUSSION Injuries associated with the use o f compression guns in industry vary widely in site and severity. Cragg (1967) reported a fatal case in which the nail entered the anterior chest wall of a young construction worker, perforated several vessels,
Lowry : Industrial Nail-gun Injuries
Allan (1970) reported a comminuted fracture of the angle of the mandible, a nail being found at operation entangled in the periosteum. Ewbank (1965) described another submandibular and cervical injury, but without bone damage. The foreign body in this case was removed from the soft tissues of the neck above the thyroid cartilage. Bala (1972) removed a nail five inches long via a palatal approach, the entry wound being in the left temporal region. A fracture of the clavicle was reported by Klenerman (1961), the patient having presented with a hard lump in the soft tissues of the supraclavicular fossa and an entry wound at the level of the left nipple in the anterior axillary line. Wilson (1962) described an unusual case of two men injured by the same nail. This passed through the left palm of the first, shattering two metacarpals, and then striking the second, in whom it tunnelled through the skin over the left pectoralis major, emerged at the anterior axillary fold, re-entered through the left deltoid, drilled a channel through the upper end of the humerus and finally emerged through the skin into the clothing. Exploration of the track revealed the plastic sleeve from the pin, which being radiolucent is often difficult to locate by radiography. Oldfield (1962) recorded a case in which the pin took a subcutaneous course in the chest and abdominal walls, and finally penetrated muscle in the left loin to come to rest in the left perinephric region. Other abdominal injuries have been reported by McMillan (1968), in whose patient the missile passed through the left kidney, spleen, stomach, diaphragm, and left ventricle. Karlstr6m and Kjellman (1971) reported a case in which a bolt entered the right flank, passed through the right lobe of the lever, right kidney, right spermatic and common iliac arteries, ricocheted off the pelvic wall to penetrate the intestinal mesentery, finally stopping retroperitoneally behind the left common iliac artery. The same authors described a further case in which there was a comminuted fracture of the radial diaphysis which required skin-grafting and internal fixation. Manning (1968), who saw four cases in five years, reported a nail embedded in the carpal bones, a facial laceration after a sliver of steel broke off a nail, and two cases of laceration from concrete shattered by impact. He also mentioned the fact that a safety-device on one type of gun could be retracted by hand, and therefore the use of the gun as a free-firing weapon was possible.
61
Neubert (1968) described four cases of eye injury in which masonry nails fractured when being driven in by an ordinary hammer and not by the nail-gun for which they were designed. Six cases were reported by H.M. Factory Inspectorate (1963) as typical of those reported each year, most of which indicated lack of training. It would therefore appear to be desirable for an approved training scheme to be instituted, following which the operator, having attained a satisfactory standard, would be licensed to operate the specific compression tools for which he had shown competence. Thus some degree of care in the use of these weapons could be ensured. The same report listed comprehensive rules for the use of the tools and gave advice on maintenance. Similar advice and information appeared in the British Standards Specification for Cartridge Operated Fixing Tools (1966). F r o m the nature and mode of causation of the injuries, it can be deduced that there are several desirable features that should be incorporated in design, if the frequency and severity of such accidents are to be reduced. These include:-1. The inability of the tool to be fired in free air. This is achieved by preventing the cartridge from being fired unless the spring-loaded barrel is pressed firmly and squarely against the fixing surface. 2. The incorporation of a non-removable shield to prevent possible ricochets or splintering of the material into which the nail is fired. 3. The prevention of firing of the gun unless the breech containing the cartridge is completely closed and locked. 4. The safe ejection of a ' misfired' cartridge. 5. The inability of a nail or bolt fired from such a tool to penetrate at high velocity a flimsy fixing surface. Several of these safeguards are contained in the British Standards Specification 4078 (1966). The last factor, however, cannot be adequately covered in the design of a high-velocity tool, and the training of the operator, both with regard to suitable surfaces on which to use the gun and the selection of the correct charge of cartridge, are of prime importance. The more widespread use of the lowvelocity tool would tend to overcome this danger, though the mechanical forces imposed on the fixing device during penetration are much greater. Improvement in nail quality and design must progress concurrently with that of tool design if accident hazards are to be reduced (Seghezzi, 1968).
62 Acknowledgements I s h o u l d like to t h a n k Mr. L. Turner, C o n s u l t a n t Surgeon, a n d Mr. W. K. Douglas, C o n s u l t a n t T h o r a c i c Surgeon, for permission to p u b l i s h this case a n d Dr. H. M c I n t y r e for advice in t h e p r e p a r a t i o n o f the paper. T h e illustrations are b y the D e p a r t m e n t o f Medical Illustration o f the University Hospital o f S o u t h M a n c h e s t e r for whose assistance I a m grateful.
REFERENCES
ALLAN, D. (1970), 'Compression gun injury ', Br. dent. J., 129, 135. BALA, S. (1972), personal communication. BRITISH STANDARDS INSTITUTE (1966), 'Specification for cartridge operated fixing tools ', Appendix A, 4078. CRAGG, J. (1967), ' Nail gun fatality ', Br. reed. J., 4, 784. EWBANK, R. L. (1965), ' Foreign body lodged in the neck; report of case ', J. oral Surg., 23, 657.
Injury: the British Journal of Accident Surgery Vol. 5/No. 1
HARPER, M. (1968), ' Play safe with cartridge tools ', Br. J. occup. Safety, 84, 409. H.M. FACTORY INSPECTORATE (1963), 'Accidents ', Ministry of Labour. KARLSTR()M, G., and KJELLMAN, T. (1971), ' Injuries caused by nail-gun accidents ', Acta chh'. scand., 137, 474. KLENERMAN, L. (1961), 'Industrial bullet wound ', Br. n, ed. J., 2, 1785. McMILLAN, I. K. R. (1968), 'Nail-gun accident ', Ibid., 1, 181. MANNING, D. P. (1968), 'Nail-gun accident', Ibid., 1, 18 I. NEUBERT, F. R. 0968), ' Nail-gun and masonry nail accidents ', Ibid. 1, 511. NORTH, J. B. (1970), ' Nail-gun injuries of the brain ', Med. J. Aust., 2, 183. OLDFIELD, M. C. (1962), 'Industrial bullet wound ', Br. reed. J., 1, 262. SEGHEZZI, H. D. (1968), ' A study of kinetic energy as a cause of accident hazards with power actuated tools ', Sichere Arbeit., 1, 5. SPENCER,G. T. (1968), ' Nail-gun accident ', Br. reed. J., 1, 181. WILSON, P. J. E. (1962), 'Industrial bullet wound ', Ibid., 1, 341.
Requests for reprints should be addressed to:--J. C. Lowry, Esq., M.B., Ch.B., B.D.S., F.D.S.R.C.S.(Eng.), M.R.C.S., L.R.C.P., 5 St. Andrew's Road, St. Anne's Park, Cheadle, Cheshire.