Incorrect Target for Nail Gun

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A 25 year old male carpenter presented to my office this afternoon with a nail gun injury, a 16d nail through the full grain leather boot, boot tongue, sock, 3rd cuneiform, 2nd and 1st cuneiform and back through the sock again. I had to cut the boot and sock off the foot, anesthetize the foot, use some pliers to remove the nail and then bandage him up. Only drops of blood came out of wounds after nail extraction. Probably won't see another one like that for a while. Made for an interesting start to my afternoon!

 

That looks like a sore one! Presumably even safety footwear wouldn't prevent penetration. What what you expect by way of a prognosis, now that the offending nail has been removed?

 

Ouch!

Looks like he might have an OC starting there as well. It never rains...

I too would like to know your prognosis. Also:-

Would you need X rays to see if there was any # or dislocation of the cunnieforms? Would you expect either of the above or would this type of injury be a clean penetration?

Apart from badaging would it be appropriate to immobilise the foot (cast)? If so why? If not why not?

What would be the risk of osteomylitis in something like this? Did you use prophalactic antibiotics?

Did any of the sock get driven into the wound? How would you check for this?

Sorry if these are really dumb questions but we don't often get to see something like this!

Regards
Robert

 

Just a thought looking at that picture.

If he'd been a bit more careful angle wise (and had a longer nail) he could have given us a really NICE picture of a Sub talar Axis to go in the text books...

 

Robert and Gavin:

The patient had only minimal pain, since he had been non-weightbearing with crutches since he left the urgent care clinic 1 hour earlier "that didn't have a big enough pliers to pull it out". I prepped the skin and prepped the nail also before pulling out the nail with my Sears Craftsman pliers I keep in the office. Since the wounds were very clean, with no signs of sock or shoe at the wounds, we just flushed the entry-exit holes with betadine solution and placed sterile 4x4s with coban as a dressing. X-rays were taken with boot on which showed penetration into dorsal bones of midfoot but no disruption of the foot skeleton otherwise. Patient was given Keflex 500 mg, QID, and Vicodin, for pain, and will be seen twice a week for the first 2 weeks to make sure he doesn't develop an infection or osteomyelitis, which is my biggest concern. I put him into a post op shoe and told him to be non weightbearing until Monday when I will see him again. I don't think he will need a splint or casting currently. I want him to be able to inspect the foot daily to report to me if there are any signs of infection developing. Pseudomonas osteomyelitis is a definite concern here, especially if some nasty organisms from the boot or sock got pushed into his cuneiforms. However, he will more than likely be back to work with his nail gun within 4 weeks, unless an infection develops.