What do you do for a nail from a nail gun in the hand? This procedure is simple, but you have to worry about the aftermath. Complicated issues may arise post-procedure in the days to weeks after extraction, including retained foreign bodies, infection, fractures, disability, pain, nerve damage, tendon rupture, and cosmetic concerns.
Removing the nail is only half the battle. Proper removal, treatment, and follow-up should be considered with all foreign bodies in the skin, especially the hand. Being prepared for the possible aftershocks will help your patient have a successful recovery.
Approximately 25,000 work‐related and consumer nail gun injuries are treated in the ED each year, according to The American Journal of Industrial Medicine. (2015;58:880.) Patients with nail gun injuries will arrive at the ED with their hands raised in the air because any movement usually causes significant pain and immobilizing the area above the heart provides temporary relief. The nail should be removed as soon as possible if there is significant bleeding so that pressure can be applied, especially if a large vessel or artery is involved. You may consider immediately injecting the area around the nail with 1% lidocaine with epinephrine to help control the bleeding and pain.
The hand and fingers have thousands of nerve innervations, which are extremely sensitive. We suggest oral or IM analgesia, or even IV opioids, to relieve pain and anxiety. Getting pain medication on board early will not only make your patients feel better, it will also relax them for the procedure to come next. Do not be stingy when treating pain related to hand injuries.
Once you have stabilized the hand, obtain x-rays to determine the extent of the injury, course and structure of the nail, and any radiopaque foreign bodies. Nails can penetrate bone and tendon or be lodged in soft tissue. Keep in mind that some nails are held together in a pack with small pieces of metal or glue that can remain in the skin after removal, making post-procedure imaging paramount.
Nails from a nail gun clip are held together with metal or glue that can be left inside a wound. Photo courtesy of Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care.
Be sure the area around the entry site is anesthetized. Distract the patient during the removal, and apply countertraction to the finger while attempting to keep the wrist and arm still. Pull the nail out of the hand or finger the same way it went in whenever possible, and don't push the nail through the hand in the direction of penetration. This will increase the chance of leaving behind rust, dirt, or debris and create unnecessary trauma. The nail head is always larger than the pointed portion, and could increase the size of the hole or cavity if pushed through.
Consider a more thorough cleaning if the nail is large and has left a significant path of destruction. Explore the entrance wound carefully, and remove any obvious foreign material. The literature is mixed when it comes to coring, carving, irrigating, and gauze clean-out. You may jet-irrigate puncture wounds that go through and through with a pressure-washing device or high-pressure tap water from the sink.
Jet lavage of the affected area.
Never insert a catheter into a puncture wound that does not go through and through. This will push debris and foreign bodies deeper into the tissue. You may consider passing a strip of gauze through the injury once or twice in the direction of initial penetration. Simply pass a small hemostat through the puncture tract, grab the gauze (suggested: ¼-inch packing gauze), and pull the gauze through the puncture tract. Do not rock the gauze back and forth through the wound like dental floss. Always irrigate copiously. The primary cause of infection post-procedure is retained foreign body.
Pass a small hemostat through the puncture wound and pull the gauze through. Photo courtesy of Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care.
The literature is somewhat mixed about prophylactic oral antibiotics preventing infection. Many hand specialists will advise giving an IV dose of cefazolin 1 g or clindamycin 600-900 mg and updating the tetanus shot. Also place the patient on something to cover staph or strep, such as oral cephalexin, amoxicillin/clavulanate, or clindamycin. Discuss the case with your specialist. It appears that simple ED removal of the nail with local debridement and a short course of antibiotics are appropriate in most cases. Operative debridement may be necessary for intra-articular or neurovascular involvement or if the wound cannot be properly irrigated or cleaned, depending on the consultant's opinion. (Injury 2008;39:357.) Occasionally, an immediate or next-day operating room wash-out by orthopedics or a hand specialist is suggested if the damage is severe or the wound is very dirty.
Nail removed from a hand.
Removal of a nail from the hand or finger.
Ninety percent of puncture wounds do well, about 10 percent get gram-positive infections, and about one percent are disasters with osteomyelitis or retained foreign material. Involve the consultant when in doubt.
-Position the patient on a stretcher so he is comfortable.
-Premedicate the patient with analgesia.
-Consider IV access, depending on the extent of injury for potential medication administration (antibiotics, analgesics). Update the tetanus shot as needed.
-Clean the injection site with Betadine or alcohol wipes; do not soak the hand or finger.
-Anesthetize the area around the puncture site using 1% lidocaine. You may use lidocaine with epinephrine for extensive bleeding. Digital blocks may also be effective.
-Image using x-ray (several views) before and after nail removal.
-Use a hemostat to grab and remove the nail in one solid motion. Try not to wiggle the nail in the space. Do not push the nail through the skin.
-Copiously irrigate the area using jet lavage or high-pressure tap water flow.
-Consider pulling a piece of gauze through the area to remove leftover debris.
-Consider oral antibiotic choice. Oral antibiotics are a reasonable idea, but are not fully supported in the literature. Cephalexin or amoxicillin/clavulanate are good choices. PCN allergic? First, determine if the patient has a true allergy, and consider clindamycin if so.
-Typically, a retained foreign body is the cause of infection.
-Consider at-home pain control.
-Splint the area if indicated for comfort or fracture.
-Consider OR washout if the wound is very dirty or complicated.
-Tendon injury or rupture is possible. Be sure to check the patient's strength and mobility after foreign body removal.
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