- Email: [email protected]
Nail gun injury: an update
Injury: International Journal of the Care of the Injured (1994) Vol. 25/No. 2
110 the femoral head and femoral neck. 224, 164. Niloff P. and Petrie J. (1950) Traumatic hip. Can. Med. Assoc. ]. 62, 574. Sadler A. H. and Di-Stefano M. (1985) hip with ipsilateral basicervical J Bone joint Surg. 67A; 326.
A case report. Clin. Orfkop. anterior dislocation
Paper accepted
20 October
1993.
of the
Anterior dislocation of the fracture. A case report.
Requests for reprints should be addressed fo: R. J. Izquierdo, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire SYlO TAG, UK.
Nail gun injury: an update B. J. C. Freeman and D. A. P. Ainscow Department
of Orthopaedic
Surgery, Cheltenham
General
Hospital,
Cheltenham,
Gloucestershire,
Introduction
Case report
Several reports exist regarding,.nail gun injuries; whether from the nail itself (Cragg, 1967), components of the gun
A left-handed 2I-year-old
(Johnson, 1974) or the explosive cartridges used (Paton, 1986). The nail gun remains a dangerous tool and its availability for public hire should be questioned. Subtle changes in design of the nail demand greater surgical care when considering their removal.
Figure 1. Radiographs index finger.
showing
0 1994 Butterworth-Heinemann 0020-1383/94/020110-02
position Ltd
UK
sustained a penetrating injury of the
dorsum of his right hand whilst erecting a fence. The site of entry was clearly visible, and sensation was intact. He was unable to extend his index finger. A pre-operative radiograph (Figure I) showed a blunt nail, with two lateral barbs, penetrating the second metacarpal. The flexed index finger confirmed the position of the hand at the time
of nail. Note the lateral barbs on the anteroposterior
projection,
and the fixed flexion of the
Case reports of the injury. Under general anaesthesia and pneumatic toumiquet the wound was explored. A longitudinal incision was used. The nail had split the tendon of extensor digitorum communis, transfixing it and the metacarpal; extensor indicis was undamaged. On attempting to remove the nail, the barbs were found to have jammed in the bone and considerable force was required. A search for embedded skin was rewarded by finding a necrotic 2 mm disc; this was duly removed. The tendon of extensor digitomm communis had not been divided, and full mobility of the index finger was restored. The wound was cleaned and closed primarily. A plaster of Paris slab was applied to the volar aspect. .After an injection of tetanus toxoid, intravenous antibiotics were administered for 48 h. The wound was inspected at 10 days and at 6 weeks by which time full function had returned.
Discussion An approved training scheme and certification in the use of these powerful tools, as suggested by Lowry (1973), is strongly endorsed by the authors. With regard to the surgical removal of these nails a number of points should be borne in mind: l A seemingly innocuous skin lesion often hides a more serious injury in the deeper tissues and exploration is required. l The blunt variety of nails may carry a disc of skin or clothing deep into the wound. This must be looked for and removed. l Nails with copper barbs can prove extremely difficult to remove and attention to the preoperative radiograph can forewarn the surgeon. These barbs can engage important structures when the nail is being removed (Figure 2); careful attention can prevent further vascular or neurological damage (Kenny et al., 1992). l
Removing
the shoulder
of the nail and advancing
Successful resuscitation report of three cases
it,
Figure 2. Barbs engaging providing
anatomical
on attempted constraints
difficult removals. l If any doubt remains regarding wounds should be left open.
removal of nail.
allow, adequate
may
facilitate
wound
toilet,
References Cragg J. (1967) Nail gun fatality. Br. Med. 1. iv, 784. Johnson R. and Campbell J. (1974) An unusual nail gun injury. Injury 6, 37. Kenny N. W., Kay P. R. and Haines, J. F. (1992) Nail gun injuries to the hand. 1. Hand Surg. 17B, 577. Lowry, J. C. (1973) Industrial nail gun injuries: review and case report. Injury 5, 59. Paton R. W. (1986) Injuries from nail gun cartridges; a dangerous new game. Br. Med. J 293, 598. Paper
accepted
20 October
1993.
Requests for reprints should be addressed to: Brian J. C. Freeman FCRS, Garden Flat, 55 Leckhampton Road, Cheltenham, Gloucestershire GL53 OBJ, UK.
from suicidal
hanging:
P. Bautz and J. D. Knottenbelt Trauma Unit, Groote
Schuur Hospital,
Cape Town, South Africa
Three cases of successful resuscitation after attempted suicide by hanging are described. Although all came in with profound unconsciousness, they made a full recovery with no residual dysfunction after resuscitation by intubation and ventilation for 12 h. Steroids and mannitol were not used. All patients were referred for psychiatric consultation before discharge from hospital.
Introduction Hanging by partial or full suspension by a ligature around the neck is a common and effective method of suicide in 0
1994 Butterworth-Heinemann
0020-1383/94/020111-02
Ltd
many communities, occurring mainly in males with depressive disorders. Very occasionally it happens accidentally when neck constriction is applied as part of an autoerotic practice. The usual cause of death in suicidal hanging is cerebral hypoxia due to airway and circulatory obstruction (mainly venous) by the ligature; the cervical spinal cord is seldom damaged as in judicial hanging. Although consciousness is lost early, cardiac arrest may only occur after a considerable time. If the constriction is relieved before cardiac arrest occurs, successful resuscitation may be possible. An early report in 1650 from Oxford (Hughes, 1982) documented resuscitation and full recovery of a
110 the femoral head and femoral neck. 224, 164. Niloff P. and Petrie J. (1950) Traumatic hip. Can. Med. Assoc. ]. 62, 574. Sadler A. H. and Di-Stefano M. (1985) hip with ipsilateral basicervical J Bone joint Surg. 67A; 326.
A case report. Clin. Orfkop. anterior dislocation
Paper accepted
20 October
1993.
of the
Anterior dislocation of the fracture. A case report.
Requests for reprints should be addressed fo: R. J. Izquierdo, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire SYlO TAG, UK.
Nail gun injury: an update B. J. C. Freeman and D. A. P. Ainscow Department
of Orthopaedic
Surgery, Cheltenham
General
Hospital,
Cheltenham,
Gloucestershire,
Introduction
Case report
Several reports exist regarding,.nail gun injuries; whether from the nail itself (Cragg, 1967), components of the gun
A left-handed 2I-year-old
(Johnson, 1974) or the explosive cartridges used (Paton, 1986). The nail gun remains a dangerous tool and its availability for public hire should be questioned. Subtle changes in design of the nail demand greater surgical care when considering their removal.
Figure 1. Radiographs index finger.
showing
0 1994 Butterworth-Heinemann 0020-1383/94/020110-02
position Ltd
UK
sustained a penetrating injury of the
dorsum of his right hand whilst erecting a fence. The site of entry was clearly visible, and sensation was intact. He was unable to extend his index finger. A pre-operative radiograph (Figure I) showed a blunt nail, with two lateral barbs, penetrating the second metacarpal. The flexed index finger confirmed the position of the hand at the time
of nail. Note the lateral barbs on the anteroposterior
projection,
and the fixed flexion of the
Case reports of the injury. Under general anaesthesia and pneumatic toumiquet the wound was explored. A longitudinal incision was used. The nail had split the tendon of extensor digitorum communis, transfixing it and the metacarpal; extensor indicis was undamaged. On attempting to remove the nail, the barbs were found to have jammed in the bone and considerable force was required. A search for embedded skin was rewarded by finding a necrotic 2 mm disc; this was duly removed. The tendon of extensor digitomm communis had not been divided, and full mobility of the index finger was restored. The wound was cleaned and closed primarily. A plaster of Paris slab was applied to the volar aspect. .After an injection of tetanus toxoid, intravenous antibiotics were administered for 48 h. The wound was inspected at 10 days and at 6 weeks by which time full function had returned.
Discussion An approved training scheme and certification in the use of these powerful tools, as suggested by Lowry (1973), is strongly endorsed by the authors. With regard to the surgical removal of these nails a number of points should be borne in mind: l A seemingly innocuous skin lesion often hides a more serious injury in the deeper tissues and exploration is required. l The blunt variety of nails may carry a disc of skin or clothing deep into the wound. This must be looked for and removed. l Nails with copper barbs can prove extremely difficult to remove and attention to the preoperative radiograph can forewarn the surgeon. These barbs can engage important structures when the nail is being removed (Figure 2); careful attention can prevent further vascular or neurological damage (Kenny et al., 1992). l
Removing
the shoulder
of the nail and advancing
Successful resuscitation report of three cases
it,
Figure 2. Barbs engaging providing
anatomical
on attempted constraints
difficult removals. l If any doubt remains regarding wounds should be left open.
removal of nail.
allow, adequate
may
facilitate
wound
toilet,
References Cragg J. (1967) Nail gun fatality. Br. Med. 1. iv, 784. Johnson R. and Campbell J. (1974) An unusual nail gun injury. Injury 6, 37. Kenny N. W., Kay P. R. and Haines, J. F. (1992) Nail gun injuries to the hand. 1. Hand Surg. 17B, 577. Lowry, J. C. (1973) Industrial nail gun injuries: review and case report. Injury 5, 59. Paton R. W. (1986) Injuries from nail gun cartridges; a dangerous new game. Br. Med. J 293, 598. Paper
accepted
20 October
1993.
Requests for reprints should be addressed to: Brian J. C. Freeman FCRS, Garden Flat, 55 Leckhampton Road, Cheltenham, Gloucestershire GL53 OBJ, UK.
from suicidal
hanging:
P. Bautz and J. D. Knottenbelt Trauma Unit, Groote
Schuur Hospital,
Cape Town, South Africa
Three cases of successful resuscitation after attempted suicide by hanging are described. Although all came in with profound unconsciousness, they made a full recovery with no residual dysfunction after resuscitation by intubation and ventilation for 12 h. Steroids and mannitol were not used. All patients were referred for psychiatric consultation before discharge from hospital.
Introduction Hanging by partial or full suspension by a ligature around the neck is a common and effective method of suicide in 0
1994 Butterworth-Heinemann
0020-1383/94/020111-02
Ltd
many communities, occurring mainly in males with depressive disorders. Very occasionally it happens accidentally when neck constriction is applied as part of an autoerotic practice. The usual cause of death in suicidal hanging is cerebral hypoxia due to airway and circulatory obstruction (mainly venous) by the ligature; the cervical spinal cord is seldom damaged as in judicial hanging. Although consciousness is lost early, cardiac arrest may only occur after a considerable time. If the constriction is relieved before cardiac arrest occurs, successful resuscitation may be possible. An early report in 1650 from Oxford (Hughes, 1982) documented resuscitation and full recovery of a