Delayed Presentation of Nail Gun-Associated Traumatic Pneumothorax with a Retained Foreign Body: A Case Report

BACKGROUND Pneumatic nail guns were first introduced in the 1950's, which revolutionized the construction industry. Since that time, nail gun injuries have been reported predominantly in the extremities with rare cases of thoracic and head injuries. A nail gun can easily propel nails through human tissue with velocities varying based on propellant and object. There are limited case reports on the appropriate management of thoracic nail gun injuries. CASE REPORT A 30-year-old man presented to the Emergency Department with right-sided chest pain seven and a half hours after getting struck in the right lateral thorax with a pneumatic nail gun. The patient was hemodynamically stable and without respiratory distress. A chest X-ray was taken and showed a right pneumothorax with a retained radio-opaque object at the right lung hilum. A CT angiogram subsequently showed the object abutting the right middle lobe branch of the pulmonary artery. Cardiothoracic surgery was called and the patient was taken urgently to the operating room for right thoracotomy, finding the nail deep in the right fissure at the hilum with the nail head in contact but not puncturing the right middle lobe branch of the pulmonary artery. The patient was extubated and recovered well postoperatively. CONCLUSIONS This case demonstrates the critical nature of nail gun injuries and can better inform the trauma protocols used to treat these injuries. Even in a delayed presentation, there should be a high suspicion of traumatic lung and cardiac injuries due to the velocities obtained with pneumatic nail guns.