From the Department of Oral and Maxillofacial Surgery (J.R.B.) and the Division of Oral and Maxillofacial Surgery, University of Pennsylvania School of Dental Medicine (L.M.L., D.C.S.), University of Pennsylvania Medical Center, Philadelphia, Pennsylvania.Address for reprints: James R. Bruno, DMD, MD, Department of Oral and Maxillofacial Surgery, University of Pennsylvania Medical Center, 3400 Spruce Street, 5 White, Philadelphia, PA 19104-4283.
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Most trauma to the maxillofacial region is from blunt injury, as seen in motor vehicle crashes, sports-related accidents, and assaults. Penetrating injury is common with firearms and knives but rarely occurs from other mechanical devices, such as pneumatic nail guns. [1,2]Nails guns have been commercially available since the 1950s. Since then, there have been many reports of bodily injury, including death, as a result of their improper use.  Nail guns are powered by a variety of sources, including compressed air (pneumatic), spring mechanisms, and explosive cartidges. [3,4] Firing a nail gun is accomplished by performing two maneuvers: applying approximately 15 lb of pressure to the tip or safety element of the gun while pulling the trigger to release a single nail. The following case details an injury from a pneumatic nail gun to the maxillofacial region, which occurred almost unbeknownst to the victim.CASE REPORTA 28-year-old male carpenter presented to the hospital of the University of Pennsylvania upon transfer from another hospital with a diagnosis of "nail in face." The patient reported using a pneumatic nail gun in the kneeling position when he fired it into a knotted area on a plank of wood. The gun recoiled, striking the patient in the right anterior maxillary region. The patient continued to work but became concerned after a few hours because of continual slow epistaxis, prompting him to present to the other hospital. Plain films of the skull revealed a nail of 4.5 in beginning in the right maxillary region and ending in the left orbital roof. He was then referred to our institution for definitive management.On initial examination at the University of Pennsylvania, the patient was found to be awake and alert, without epistaxis, complaining of right cheek pain and double vision upon upward gaze. He was afebrile with stable vital signs. The pupils were equal, round, and reactive to light and accommodation. Examination of ocular movement revealed a restriction of upward gaze with the left eye; diplopia was elicited upon upward gaze. Visual acuity was 20/25 for both eyes. There was a 1-cm skin laceration in the right anterior maxillary region and periorbital edema of the left eye. Dried blood was noted in the nares. Intraorally, tenderness to palpation was elicited in the right anterior maxillary mucobuccal fold overlying a 4-mm firm mass. There was no evidence of mucosal or gingival lacerations or ecchymosis. Cranial nerves II though XII were intact, with the exception of an infraorbital paresthesia on the right. The remainder of the patient's physical examination was unremarkable.A facial series revealed a 4.5-in nail through the right maxillary sinus, crossing the nasal septum, and ending in the left supermedial orbital wall (Figure 1 and Figure 2). Computed tomography revealed that the nail oriented in a supermedial angulation, arising at the right piriform rim, traversing the maxillary sinus, nasal septum, and ethmoid sinus, and ending superior and medial to the left orbital wall. It also revealed left periorbital soft-tissue swelling. The left globe was intact, and there was no orbital hemorrhage or intracranial involvement. Laboratory values revealed a white blood count of 7,600 thousand/mL and a hemoglobin of 15.2 g/dL.The patient was admitted to the oral and maxillofacial surgery service and started on ticarcillin and clavulanic acid (Timentin) and intravenous steroids. Tetanus booster was given upon presentation. An ophthalmology consultation confirmed no evidence of globe rupture but restriction in upward gaze in the left eye secondary to periorbital edema.