Man with wrist pain.

CASE PRESENTATION

A man presented to the emergency department complaining of right wrist pain and distal paresthesias after sustaining a nail gun injury. His vital signs were unremarkable, and on examination there was a nail penetrating through the patient's wrist (Figure 1). The emergency physicians performed point‐of‐care ultrasound to evaluate for vascular injury (Figure 2, Video S1) and an X‐ray (Figure 3) was performed to look for fracture.

FIGURE 1

Nail penetrating the ulnar aspect of the distal right forearm

FIGURE 2

Ultrasonographic image of the nail penetrating just adjacent to the ulnar artery

FIGURE 3

Anterior‐posterior and lateral X‐ray images showing the distal forearm medial to the ulna impaled by the nail without signs of fracture

DIAGNOSIS

Vascular injury after nail gun penetration

Point‐of‐care ultrasound confirmed that the nail barely missed the ulnar artery as shown in Figure 2 and Video S1. X‐ray showed no bony involvement.

DISCUSSION

When managing nail gun injuries, it is important to maintain the nail in place, and point‐of‐care ultrasound should be used as a timely modality to evaluate for vascular injury. Ultrasound can also be used to detect penetrating nerve injury as was done at the bedside given the proximity to the ulnar nerve. Although ultrasound also has been shown to assist in the evaluation of fracture, we decided ​x‐ray was low risk and indicated in this case. As with other bedside ultrasound applications, it is important to evaluate the structure of interest in multiple planes to fully assess neurovascular structures. Injuries should be managed by updating the patient's tetanus and administering a first‐generation cephalosporin antibiotic. If there is no damage to surrounding tissue or intraarticular penetration, the nail can be removed at the bedside, and the patient can be discharged with 1 week of oral antibiotics and hand surgery follow‐up care.

Supplementary information

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