Nail gun injuries to the head with minimal neurological consequences: a case series
Makoshi et al. Journal of Medical Case Reports
Nail gun injuries to the head with minimal neurological consequences: a case series
Ziyad Makoshi 0 1
Fahad AlKherayf 0
Vasco Da Silva 0
Howard Lesiuk 0
0 Division of Neurosurgery, Department of Surgery, The Ottawa Hospital - Civic Campus , Ottawa, ON , Canada
1 Department of Surgery, College of Medicine, Prince Sattam Bin Abdulaziz University , Al-Kharj , Saudi Arabia
Background: An estimated 3700 individuals are seen annually in US emergency departments for nail gun-related injuries. Approximately 45 cases have been reported in the literature concerning nail gun injuries penetrating the cranium. These cases pose a challenge for the neurosurgeon because of the uniqueness of each case, the dynamics of high pressure nail gun injuries, and the surgical planning to remove the foreign body without further vascular injury or uncontrolled intracranial hemorrhage. Case presentation: Here we present four cases of penetrating nail gun injuries with variable presentations. Case 1 is of a 33-year-old white man who sustained 10 nail gunshot injuries to his head. Case 2 is of a 51-year-old white man who sustained bi-temporal nail gun injuries to his head. Cases 3 and 4 are of two white men aged 22 years and 49 years with a single nail gun injury to the head. In the context of these individual cases and a review of similar cases in the literature we present surgical approaches and considerations in the management of nail gun injuries to the cranium. Case 1 presented with cranial nerve deficits, Case 2 required intubation for low Glasgow Coma Scale, while Cases 3 and 4 were neurologically intact on presentation. Three patients underwent angiography for assessment of vascular injury and all patients underwent surgical removal of foreign objects using a vice-grip. No neurological deficits were found in these patients on follow-up. Conclusions: Nail gun injuries can present with variable clinical status; mortality and morbidity is low for surgically managed isolated nail gun-related injuries to the head. The current case series describes the surgical use of a vice-grip for a good grip of the nail head and controlled extraction, and these patients appear to have a good postoperative prognosis with minimal neurological deficits postoperatively and on follow-up.
Brain; Nails; Neurosurgery; Penetrating trauma
Pneumatic nail guns are commonly used in residential
construction but also easily accessible at hardware stores
to public consumers. A 2005 report by the Centers for
Disease Control and Prevention (CDC) reported that
nail gun-related injuries have increased threefold in the
USA since 1991 with an estimated 37,000 patients being
seen annually in emergency departments (EDs) for nail
gun-related injuries from 2001 to 2005 [
]. Males were
the predominant gender treated for such injuries [
with an average age of 27 years among workers [
and 35 years among consumers [
The majority of traumatic injuries involved the upper
]; however, intracranial injuries have been
reported as a work-related or intentional injury [
Injuries due to penetrating trauma to the head include
immediate complications via direct neurological or
vascular injury, and delayed complications via vascular
malformations and infection through contamination with
bone or foreign body fragments.
The approach to these injuries has been largely similar
to that of penetrating foreign bodies [
]. Here we
present a case series of four patients presenting to our
ED with penetrating nail gun injuries to the head with
minimal neurological complications as well as approach
considerations and surgical technique in removing these
Preoperatively, all patients received antibiotics
administered intravenously and a tetanus shot. After imaging
and evaluation for vascular injury, the patients were
taken to the operating room (OR). Intraoperatively, the
patients were positioned for proper exposure; we shaved
the head of each patient and prepped around the injury
site(s), each patient’s head was again examined to
identify the entry point of all the foreign bodies.
A skin incision was made over the nail entry point and
extended down to the nail. After dissection down to the
cranial vault the skull was again examined to identify the
entry point of all foreign objects. After debridement, a
small craniectomy was done around the nail followed by
opening of the dura around the nail in a cruciate
fashion. The nail was removed carefully to avoid excessive
movement of those nails and injury to surrounding
structures. When the nail was difficult to grasp or was
met with resistance, a vice-grip was used to grip the
head of the nail for extraction.
After removing the nail(s), some sites had minimal
bleeding from minor cortical vessels which was easily
controlled with bipolar cautery. The entry point was
inspected for several minutes and irrigated with normal
saline followed by hydrogen peroxide or antimicrobial
solution. Each patient’s head was positioned for optimal
approach for each injury; after extraction at one site
each patient’s head was again positioned for an optimal
approach to other sites in the cases with multiple
injuries and we proceeded in a similar fashion.
After extraction of all foreign objects, the nails were
examined to ensure they were intact and that the count
was complete and no further objects were left in the
cranial vault. In the first case of ten nails, an intraoperative
skull X-ray was used to evaluate the removal of all
foreign objects. After establishing complete removal and
control of bleeding, the wound was closed in the typical
fashion. All patients received a 1-week postoperative
course of phenytoin as per our institutional practice;
however, no patient received prophylactic antiepileptic
medication prior to surgery or beyond 1 week after
surgery as there was no clinical evidence of seizure activity
in any of our patients. All patients underwent a
postoperative computed tomography (CT) scan to evaluate for
bleeding and complete removal of all foreign objects,
and the nails were sent for microbiology testing.
A 33-year-old, right-handed white man with a history of
severe depression was transferred to our Neurosurgical
unit after he shot himself in the head with a nail gun ten
times. He was alert on arrival and described that he shot
himself on the right side five times in different locations,
and then shot himself on the left side in another five
locations. Examination revealed left CN VI, VIII, XI and
XII injury. A motor examination showed that he had
slight weakness on his left side (4/5). A head
examination revealed only eight identifiable nails at the surface
of his skull. He underwent a CT and CT angiogram
(Fig. 1) which showed ten nails in his
temporo-parietooccipital area bilaterally, five on each side, with no
evidence of major vessel injury and he was subsequently
taken for surgical extraction of the nails (Fig. 2a).
A 51-year-old white man with known alcohol abuse
presented to our ED with self-inflicted bilateral temporal
injury using a 3-inch (7.62 cm) nail gun (Fig. 2b) after
being involved in what seemed to be a social dispute
with his partner. On arrival in our ED, his Glasgow
Coma Scale (GCS) score was 8/15 but it soon decreased
to 6 and he was intubated. Before surgical exploration,
he underwent a CT, CT angiogram and cerebral
angiogram (Fig. 3), which showed two nails penetrating his
calvarium on each side and no definite contrast
extravasation or direct vascular injury.
A 22-year-old, white right-handed man, with a known
history of schizophrenia and previous history of
psychotic episodes, had apparently attempted to kill himself
by placing a nail gun to his head and pulling the trigger.
Fortunately, this was a Brad Nail Gun ejecting
approximately 1.5-inch (3.81 cm) long nails of a small diameter,
so although the nail did penetrate his skull and pierce
his right frontal brain parenchyma, there was no
significant bleeding associated with it, nor was there a
significant clinical deficit. He did not lose consciousness and
on presentation to our ED he was neurologically intact.
He underwent CT of his head without contrast (Fig. 4)
and was taken to our OR.
A 49-year-old white man sustained a self-inflicted nail
gun injury that entered the intracranial cavity at the
posterior aspect of his right ear lobe. The nail produced an
opening in his earlobe and it was inserted up to the nail
head inside his cranial cavity. It came with a metallic
collar measuring 1.5 cm in diameter that pushed the
skin of his scalp against the bone. Due to a low GCS the
patient was intubated. When he was off sedation, an
examination showed no neurological deficits. A CT and
cerebral angiogram (Fig. 5) were obtained which showed
the foreign body had transected the superior aspect of
his right transverse sinus; however, there was no active
extravasation of contrast or evidence of major arterial or
venous compromise and he was taken to our OR.
Postoperatively these patients recovered without any major
complications. Case 1 had no neurological deficits
postoperatively; neuropsychological assessment showed
moderateto-severe cognitive impairment with improvement upon
assessment at 3 months with persistent moderate cognitive
impairment and a score of 26/30 on the Montreal
Cognitive Assessment (MoCA) test. Case 2 experienced a few
days of confusion and aggressive behavior that resolved;
postoperative neuropsychological assessment showed
difficulties with complex attention, memory and executive
functions, these improved at reassessment at 5 months with
persistent mild-to-moderate cognitive impairment and a
MoCA score of 20 + 1/30 with the belief that some of
these deficits were probably premorbid. Case 3 had no
neurological deficits postoperatively or on follow-up at
5 months but continues to be followed by psychiatry
for issues regarding his chronic schizophrenia. Case 4 had
some unsteadiness of gait during the postoperative period
that resolved; he received psychological assessment at
another institute for which the records could not be
obtained. All patients received physiotherapy as part of their
rehabilitation. Follow-up imaging of these patients at 3 to
5 months with a CT of their head without contrast
showed no hemorrhage and areas of encephalomalacia
corresponding to the injury sites, as expected.
Nail gun injuries are commonly reported in the workplace
]. Trigger mechanisms include contact triggers whereby
a nail is discharged when there is depression of the nose
piece of the gun and the trigger simultaneously; this type
of mechanism has been associated with increased risk of
accidental injury to self and others [
]. However, a
sequential actuation system has been shown to decrease the
incidence of non-intended firing whereby the nail is only
discharged if the nose element is depressed before pressing
the trigger. The air pressure on these devices can be
between 80 and 120 psi, often sufficient enough to penetrate
the scalp [
], and can reach projectile speeds of up to 100
to 150 m/second [
]. Experiments with high pressure
injuries on human hand cadavers showed that the lateral
distribution of energy is limited and that the majority of
the trauma occurs along the path of penetration [
The aforementioned cases of nail gun injuries,
however, were all self-inflicted and in the setting of
psychiatric disorder or substance abuse. Initial impact during
such injury is usually painless [
]. The patients often
present fully conscious; our patients’ history was
informative in assessing the true number of injuries confirmed
on subsequent imaging. No signs of active hemorrhage
were present, and the patient’s status in all four cases
was stable to warrant complete workup including
imaging to identify foreign objects and angiogram to assess
for vascular injury. Mortality following these injuries is
low, and those reported in the literature are due to
concomitant injury to other parts of the body [
penetration with a larger object such as a steel rod [
The most common complications reported after
penetrating nail gun trauma are vascular injury [
2, 10, 13, 20
and intracranial hemorrhage [
6, 21, 23
]. When injury to
a major intracranial artery has occurred these can lead to
substantial subarachnoid and intraventricular hemorrhage
with subsequent complications including hydrocephalus,
ischemia and death . A favorable outcome has been
reported in the case of basilar artery injury when a clot
acted as a tamponade for the vascular injury and care was
taken, intraoperatively, to obtain distal control using
vascular clipping and preparations for proximal control
using balloon occlusion in the event extravasation
occurred during extraction of the nail [
]. Reports of
venous injuries show variable outcomes; a case involving
injury to the superior sagittal sinus with successful nail
extraction and venous repair had a good outcome with no
neurological deficits [
], while a nail gun injury involving
the left transverse sinus resulted in residual right
hemiparesis even after extraction of the nail and repair of the
venous injury [
Development of cerebral aneurysms and
pseudoaneurysms have been reported [
5, 14, 21, 24
]; these may be
obvious on postoperative imaging  or may develop in
a delayed fashion [
]. Involvement of a cerebrovascular
neurosurgeon and interventional neuroradiologist is
indicated in these cases and management should be
individualized based on location, size, and characterization, and
may include observation, surgical clipping, or
endovascular coiling as indicated.
An approach to patients with nail gun injuries involves
detailed history and neurological examination, and
examination for other injuries. When patient stability
permits, imaging with CT and angiogram should be
performed to assess for number, location, and associated
vascular injury and for surgical planning. Although
injuries from nail guns are often considered “clean” with
report of successful removal without antibiotic
], we recommend tetanus prophylaxis and
antibiotics in these patients in light of the high rate of
infection reported in other penetrating brain injuries [
] and possible introduction of skin, bone or foreign
body fragments into the wound . The surgical
approach to these injuries should include proper exposure
through craniotomy for direct visual inspection of injury
sites. Care should be taken when removing these objects
to avoid additional injury with extraction, and the injury
site should be properly examined to assess for hemorrhage
after removal with thorough irrigation and debridement of
the wound site. A vice-grip in our experience has been
helpful in getting control of the nail head for a smooth
removal even after exposing the nail intraoperatively to limit
injury to surrounding structures during nail extraction.
An intraoperative X-ray may be indicated when multiple
sites are present to evaluate for any remaining foreign
Nail gun injuries are often self-inflicted and associated
with a background of a psychiatric disorder. Involvement
of the appropriate services during hospital care,
including psychiatric evaluation, is indicated in these settings.
Proper evaluation with history and physical examination,
as well as vascular imaging assists in management
planning for these patients and should be obtained upon
presentation when possible. Craniotomies and wound
debridement is the standard approach for penetrating
injuries and the use of vice-grips for removal of nails in
our experience facilitates nail extractions with good
control. Although presentation is variable among patients,
most present with minimal neurological deficits,
mortality and morbidity is low for surgically managed isolated
nail gun-related injuries to the head and these patients
appear to have a good postoperative prognosis with
Written informed consent was obtained from the
patients for publication of this case series and
accompanying images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
ZM collected patient data and was involved in writing and in a review of the
manuscript. FA was a major contributor in writing and in a review of the
manuscript. VD was involved in patient management and review of the
manuscript. HL was involved in patient management and review of the
manuscript. All authors read and approved the final manuscript.
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