Sharp cardiac trauma through the sternum caused by an automatic nail gun: A case report

Abstract

Automatic nail gun injuries to the hand commonly occur with the use of these machines in construction. However, such injuries to the cardiothoracic area are atypical. Herein, we report a case of emergency surgery to remove a nail, which was accidentally shot through the sternum and reached the heart. A 24-year-old man was working in a narrow space at a construction site, where he tripped over the air hose of an automatic pneumatic nail gun. The trigger was accidentally pulled, while the machine was facing his direction, and a nail entered his sternum. The patient felt chest pain, walked to a nearby orthopedic clinic, and then was transferred to our hospital for treatment. On examination, the nail was completely embedded in the midline of the precordial chest. Chest X-ray and computed tomography (CT) images showed a rod-shaped nail penetrating the sternum from the precordial region and reaching the anterior medi-astinum. The nail tip was located between the pulmonary artery and the aorta; it was touching the main trunk of the pulmonary artery. Emergency surgery was performed to remove the 45-mm-long nail (2 mm in diameter) on the same day, considering the possibility of massive bleeding and infection. An auxiliary circulatory system was not used, and intraoperative blood transfusion was not required. The patient was extubated on the same day. On post-operative day 7, CT confirmed that there were no issues of concern and no signs of infection. The patient was discharged on post-operative day 8 and returned home on foot. The patient was followed up for 6 months in the outpatient clinic, and there were no signs of infection or abnormal hemodynamics. This case demonstrates the need for careful assessment of nail gun injuries, which may initially appear insignificant.

Figure 1

Photograph of the precordial chest on presentation. The nail is completely embedded in the midline of the precordial chest, and there is no bleeding (white arrow).

Figure 2

(a) Chest radiograph taken on admission. The chest radiograph reveals a cardiothoracic ratio of 52%, no mediastinal enlargement or pleural effusion, and no other obvious lung lesions. An opaque shadow of a foreign body is observed in the sternum and in the area overlapping the cardiac shadow (blue arrow). Axial (b), sagittal (c), and three-dimensional computed tomography (d) images obtained on admission show a rod-shaped nail penetrating the sternum from the precordial region to the anterior mediastinum. The nail tip is between the pulmonary artery and the aorta and is in contact with the main trunk of the pulmonary artery. Mediastinal hematoma and cardiac tamponade are not identified (white arrows).

Figure 3

Photograph of the cranial and caudal operative field. The nail is on the left side of the sternum. The posterior (caudal) surface of the sternum reveals that the nail tip is buried in the anterior (cranial) mediastinal thymus tissue. The nail has reached the heart, and the tip of the nail is between the pulmonary artery and the aorta (white arrows).

Figure 4

Photograph of the extracted nail. The nail is 45 mm long and 2 mm in diameter.