Nail gun injuries in apprentice carpenters: risk factors and control measures

Nail gun injury to the median nerve: A barbed issue

Nail gun injuries to the hand are an increasingly common encounter amongst those in the construction injury and a frequent presentation to the emergency department. Despite their frequency, nail gun injuries rarely involve significant structural injury. We present a rare case of severe injury by a barbed nail to the median nerve requiring surgical exploration. At our latest follow up 14 months post-operatively, the patient had ongoing sensory and motor deficits, cold intolerance and reduced proprioception and range of motion at the index finger. Continued hand therapy resulted in improved range of motion and desensitization. A systematic literature search has revealed no other reported cases of median nerve injury by nail gun.

Nail Gun Suicide: An Atypical Case Report and Review of the Literature

ABSTRACT

Nail guns are pneumatically driven or powder-actuated tools, which are used to drive nails into wood or concrete. A 42-year-old man, who was a builder by profession and history of antidepressant use, was found dead in his vehicle, holding a "Ramset" nail gun in his right hand. A straight metal nail and a book with a small hole were recovered from the scene.At autopsy, an irregularly circular puncture wound was seen on the forehead and a cruciate laceration was seen on the posterior aspect of the scalp. No burning, blackening, or tattooing was present around either injury. Both internal and external beveling was present with the latter being relatively larger. Toxicological analysis revealed alcohol and methamphetamine in blood. Psychiatric history and substance abuse must also be considered when individuals in construction industry are given access to tools like nail guns.Several unique features not previously reported were observed in this case. The deceased had overcome the built-in safety mechanism of the nail gun, by placing a book in between his forehead and muzzle. Another unique feature is that the nail had exited the cranium. Beveling, a feature commonly found in firearm injuries, was also seen in this case.

Understanding Nail Gun Injuries in Orthopedics: Mechanisms and Treatment

Nail gun injuries are common among users, and most frequently involve the hands and lower extremities. A wide variation in costs and time are missed from work due to these injuries, and training on the proper use of nail guns has been shown to decrease workplace-related injuries. Minimal long-term disability can be expected, and orthopedic evaluations provide an opportunity to inform patients on proper use of these devices. In this article, management of nail gun injuries is discussed, including the necessity for a high suspicion for wound contamination because foreign material is often deposited with the nail, as well as treatment with debridement and antibiotics. [Orthopedics. 2019; 42(5):e410-e414.].

The new ANSI nail gun standard: A lost opportunity for safety

Pneumatic nail guns have been shown in published studies to cause injury and death to both workers and consumers, but those equipped with sequential trigger mechanisms provide much greater safety protection against unintentional discharge than those equipped with contact triggers. In 2015 the American National Standards Institute (ANSI) approved a revision to its 2002 nail gun standard, but failed to require sequential triggers. Substantive and procedural deficiencies in the ANSI standard's development process resulted in a scientifically unsound nail gun safety standard, detracting from its use as the basis for a mandatory national safety standard and ultimately from its ability to protect worker and consumer users. Am. J. Ind. Med. 60:147-151, 2017. © 2016 Wiley Periodicals, Inc.

Pericardiocentesis followed by thoracotomy and repair of penetrating cardiac injury caused by nail gun injury to the heart

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Nail gun injuries to the heart are potentially fatal and difficult to recognize.

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Timely recognition and definitive repair of the injury is essential for patient survival.

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Pericardiocentesis using a catheter capable of repeated and/or sustained aspiration/drainage can be a temporizing life-saving measure allowing for definitive repair in a controlled setting.

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Pericardiocentesis must be considered as a bridge to definitive therapy in select cases of penetrating cardiac injury, particularly in rural settings with limited surgeon availability.

Introduction

Work site injuries involving high projectile tools such as nail guns can lead to catastrophic injuries. Generally, penetrating cardiac injuries are associated with a high mortality rate.

Presentation of case

A construction worker was brought to the emergency room having sustained a nail gun injury to the chest. The patient was hypotensive, tachycardic with prominent jugular venous distention, and had a profound lactic acidosis. Bedside ultrasound confirmed the presence of pericardial fluid. Pericardiocentesis was performed twice using a central venous catheter inserted into the pericardial space, resulting in improvement in the patient’s hemodynamics. Thereafter he underwent left anterolateral thoracotomy and repair of a right atrial laceration. He recovered uneventfully.

Discussion

Penetrating cardiac injuries caused by nail guns, although rare, have been previously described. However, pericardiocentesis, while retaining a role in the management of medical causes of cardiac tamponade, has been reported only sporadically in the setting of trauma. We report a rare case of penetrating nail gun injury to the heart where pericardiocentesis was used as a temporizing measure to stabilize the patient in preparation for definitive but timely operative intervention.

Conclusion

We propose awareness that percardiocentesis can serve as a temporary life saving measure in the setting of trauma, particularly as a bridge to definitive therapy. To our knowledge, this represents the first reported case of catheter pericardiocentesis used to stabilize a patient until definitive repair of a penetrating cardiac injury caused by a nail gun.

Nail gun injuries to the head with minimal neurological consequences: a case series

Background

An estimated 3700 individuals are seen annually in US emergency departments for nail gun-related injuries. Approximately 45 cases have been reported in the literature concerning nail gun injuries penetrating the cranium. These cases pose a challenge for the neurosurgeon because of the uniqueness of each case, the dynamics of high pressure nail gun injuries, and the surgical planning to remove the foreign body without further vascular injury or uncontrolled intracranial hemorrhage.

Case presentation

Here we present four cases of penetrating nail gun injuries with variable presentations. Case 1 is of a 33-year-old white man who sustained 10 nail gunshot injuries to his head. Case 2 is of a 51-year-old white man who sustained bi-temporal nail gun injuries to his head. Cases 3 and 4 are of two white men aged 22 years and 49 years with a single nail gun injury to the head. In the context of these individual cases and a review of similar cases in the literature we present surgical approaches and considerations in the management of nail gun injuries to the cranium. Case 1 presented with cranial nerve deficits, Case 2 required intubation for low Glasgow Coma Scale, while Cases 3 and 4 were neurologically intact on presentation. Three patients underwent angiography for assessment of vascular injury and all patients underwent surgical removal of foreign objects using a vice-grip. No neurological deficits were found in these patients on follow-up.

Conclusions

Nail gun injuries can present with variable clinical status; mortality and morbidity is low for surgically managed isolated nail gun-related injuries to the head. The current case series describes the surgical use of a vice-grip for a good grip of the nail head and controlled extraction, and these patients appear to have a good postoperative prognosis with minimal neurological deficits postoperatively and on follow-up.

Nail gun injuries treated in U.S emergency departments, 2006-2011: not just a worker safety issue

BACKGROUND

Nail guns increase productivity in residential building but with a corresponding increase in worker injuries. They are also easily accessible, at low cost, to consumers.

METHODS

Data from the occupational supplement to the National Electronic Injury Surveillance System (NEISS-Work) were used to calculate national estimates of work-related injuries from nail guns between 2006 and 2011. These were compared to estimates of consumer injuries obtained through online access to the Consumer Product Safety Commission's (CPSC) NEISS data.

RESULTS

Approximately 25,000 ED-treated work-related and consumer nail gun injuries were estimated each year. During the construction economy collapse, injuries among workers declined markedly, closely following patterns of reduced residential employment. Reduction in consumer injuries was much more modest.

CONCLUSIONS

Current nail gun injury patterns suggest marked blurring of work and home exposures. A united effort of CPSC, NIOSH, and OSHA is warranted to address these preventable injuries.

Non-reporting of work injuries and aspects of jobsite safety climate and behavioral-based safety elements among carpenters in Washington State

BACKGROUND

Declining work injury rates may reflect safer work conditions as well as under-reporting.

METHODS

Union carpenters were invited to participate in a mailed, cross-sectional survey designed to capture information about injury reporting practices. Prevalence of non-reporting and fear of repercussions for reporting were compared across exposure to behavioral-based safety elements and three domains of the Nordic Safety Climate Questionnaire (NOSACQ-50).

RESULTS

The majority (>75%) of the 1,155 participants felt they could report work-related injuries to their supervisor without fear of retribution, and most felt that the majority of injuries on their jobsites got reported. However, nearly half indicated it was best not to report minor injuries, and felt pressures to use their private insurance for work injury care. The prevalence of non-reporting and fear of reporting increased markedly with poorer measures of management safety justice (NOSACQ-50).

CONCLUSIONS

Formal and informal policies and practices on jobsites likely influence injury reporting.

Musculoskeletal concerns do not justify failure to use safer sequential trigger to prevent acute nail gun injuries

BACKGROUND

Acute nail gun injuries can be controlled significantly by using tools with sequential triggers and training. Concern has been raised that sequential triggers, which require that the nose piece of the gun be depressed prior to pulling the trigger, could increase risk of musculoskeletal problems.

METHODS

We conducted active injury surveillance among union carpenter apprentices to monitor acute injuries and musculoskeletal disorders between 2010 and 2013.

RESULTS

Acute injury risk was 70% higher with contact trip rather than sequential triggers. Musculoskeletal risk was comparable (contact trip 0.09/10,000 hr (95% CI, 0.02-0.26); sequential 0.08/ 10,000 hr (95% CI 0.02-0.23)).

CONCLUSIONS

Concern about excess risk of musculoskeletal problems from nail guns with sequential triggers is unwarranted. Both actuation systems carry comparable musculoskeletal risk which is far less than the risk of acute injury; there is clearly no justification for failure to prevent acute injuries through use of the safer sequential trigger.

Piecewise exponential models to assess the influence of job-specific experience on the hazard of acute injury for hourly factory workers

Background

An inverse relationship between experience and risk of injury has been observed in many occupations. Due to statistical challenges, however, it has been difficult to characterize the role of experience on the hazard of injury. In particular, because the time observed up to injury is equivalent to the amount of experience accumulated, the baseline hazard of injury becomes the main parameter of interest, excluding Cox proportional hazards models as applicable methods for consideration.

Methods

Using a data set of 81,301 hourly production workers of a global aluminum company at 207 US facilities, we compared competing parametric models for the baseline hazard to assess whether experience affected the hazard of injury at hire and after later job changes. Specific models considered included the exponential, Weibull, and two (a hypothesis-driven and a data-driven) two-piece exponential models to formally test the null hypothesis that experience does not impact the hazard of injury.

Results

We highlighted the advantages of our comparative approach and the interpretability of our selected model: a two-piece exponential model that allowed the baseline hazard of injury to change with experience. Our findings suggested a 30% increase in the hazard in the first year after job initiation and/or change.

Conclusions

Piecewise exponential models may be particularly useful in modeling risk of injury as a function of experience and have the additional benefit of interpretability over other similarly flexible models.

Residential building stakeholders' attitudes and beliefs regarding nail gun injury risks and prevention

Pneumatic nail guns are ubiquitous at residential construction sites across the United States. These tools are noted for the traumatic injuries that can occur from their operation. Different trigger mechanisms on these tools are associated with different levels of risk. Residential building subcontractors and workers, both native-born and immigrant, were brought together in focus groups to discuss their attitudes and beliefs regarding risk factors for nail gun injury as well as barriers to the adoption of safer technology. Participants' comments are organized first by influences on traumatic injury occurrence or prevention and later by sociotechnical system category. Participants attributed influences on injury risk to personal and external causation factors in all sociotechnical system categories; however, participants more frequently described influences on injury prevention as related to workers' behaviors, rather than to external factors. A discussion of these influences with respect to attribution theory and sociotechnical models of injury causation is presented.

Buyer beware: personnel selling nail guns know little about dangerous tools

BACKGROUND

Nail gun use is ubiquitous in wood frame construction. Accessibility and decreasing costs have extended associated occupational hazards to consumers. Compelling evidence documents decreased injury risk among trained users and those with tools with sequential triggers. To prevent inadvertent discharge of nails, this safer trigger requires the nose be depressed before the trigger is pulled to fire. The sequential trigger is not required by the Consumer Product Safety Commission (CPSC) or the Occupational Safety and Health Administration (OSHA) nor are there any guidelines for training.

METHODS

We collected data from personnel at 217 points of sale/rental of framing nail guns in four areas of the country.

RESULTS

Sales personnel had little understanding of risks associated with use of framing nail guns. Individuals who had used the tool and those working in construction outlets were more likely to be knowledgeable; even so, less than half understood differences in trigger/actuation systems.

CONCLUSIONS

Consumers, including contractors purchasing for workers, cannot count on receiving accurate information from sales personnel regarding risks associated with use of these tools. The attitudes and limited knowledge of some sales personnel regarding these potentially deadly tools likely contributes to a culture accepting of injury. The findings demonstrate how influences on the culture of construction are not limited to workers, employers, or the places construction gets done.

Perspectives of residential contractors on nail gun safety

Perspectives on nail gun safety were sought from residential contractors as part of an injury surveillance and prevention effort (2005-2008). Anonymous surveys inquired about tool use, training, injury risk, and awareness of the 2003 American National Standards Institute (ANSI) standard calling for shipment of pneumatic nail guns used in wood framing with sequential actuation. Despite some awareness of inexperience, lack of training, speed and tool design in injury causation, 55 percent consistently reported injuries resulted from worker carelessness. Contractors reported safety experiences of their employees were considerably better than those of other residential contractors. After five years, only 16 percent reported any awareness of the voluntary standard. These findings raise questions as to what gains can realistically be expected from passage of voluntary standards such as the one described here. Given that the epidemiology of acute injuries from pneumatic nail guns is now well-described, the safer sequential trigger should be required to protect workers.

Surveillance of nail gun injuries by journeymen carpenters provides important insight into experiences of apprentices

Experienced journeymen conducted detailed surveillance interviews with injured apprentice carpenters (n = 413). Nail gun injuries commonly occurred due to inadvertent discharge, ricocheting or projectile nails, and penetration of the wood surface. Framing nailers with contact trip triggers were most often involved; these triggers allow nail discharge anytime the trigger and nose piece are both depressed including following recoil of the tool after firing. Injured workers made concrete and practical suggestions for prevention. Scenarios were identified where changes in work practice, safer triggers, and thoughtful training could prevent injuries. Most injuries were not reported through workers' compensation; this was often due to perceived lack of injury severity, but also involved subtle as well as overt pressures on apprentices not to report. These case-based analyses are consistent with reports that many injuries from nail guns could be prevented with existing safer trigger mechanisms and training. Efforts should also focus on improved injury reporting.

Continued progress in the prevention of nail gun injuries among apprentice carpenters: what will it take to see wider spread injury reductions?

PROBLEM

Nail guns are a common source of acute, and potentially serious, injury in residential construction.

METHOD

Data on nail gun injuries, hours worked and hours of tool use were collected in 2008 from union apprentice carpenters (n=464) through classroom surveys; this completed four years of serial cross-sectional data collection from apprentices. A predictive model of injury risk was constructed using Poisson regression.

RESULTS

Injury rates declined 55% from baseline measures in 2005 with early training and increased use of tools with sequential actuation. Injury rates declined among users of tools with both actuation systems, but the rates of injury were consistently twice as high among those using tools with contact trip triggers. DISCUSSION AND IMPACT: Nail gun injuries can be reduced markedly through early training and use of tools with sequential actuation. These successful efforts need to be diffused broadly, including to the non-union sector.

Nonfatal tool- or equipment-related injuries treated in US emergency departments among workers in the construction industry, 1998-2005

BACKGROUND

Individuals in the construction industry are exposed to a variety of tools and pieces of equipment as they work.

METHODS

Data from the National Institute for Occupational Safety and Health (NIOSH) occupational supplement to the National Electronic Injury Surveillance System (NEISS-Work) were used to characterize tool- and equipment-related injuries among workers in the construction industry that were treated in US emergency departments between 1998 and 2005. Based on a national stratified probability sample of US hospitals with 24 hr emergency services, NEISS-Work allows calculation of national injury estimates.

RESULTS

Over the 8-year period between 1998 and 2005, we estimated 786,900 (95% CI 546,600-1,027,200) ED-treated tool- or equipment-related injuries identified by the primary or secondary source of injury code. These injuries accounted for a quarter of all ED-treated construction industry injuries. Although over 100 different tools or pieces of equipment were responsible for these injuries, seven were responsible for over 65% of the injury burden: ladders, nail guns, power saws, hammers, knives, power drills, and welding tools in decreasing order.

CONCLUSIONS

Current injury estimates and their severity, marked by the proportion of cases that were not released after ED treatment, indicate interventions are particularly needed to prevent injuries associated with use of ladders as well as nail guns and power saws. Attention should focus on design and guarding to more efficiently prevent these injuries rather than simply calling for the training of workers in how to safely use a dangerous tool or piece of equipment.

Prevention of traumatic nail gun injuries in apprentice carpenters: use of population-based measures to monitor intervention effectiveness

INTRODUCTION

Nail guns are responsible for a significant injury burden in residential construction. Risk, based on hours of work, is particularly high among apprentice carpenters due in part to more frequent exposure to tool use.

METHODS

Nail gun injuries were evaluated over 3 years among carpenters enrolled in two apprenticeship programs in the Midwest (2.3 million residential work hours observed) following initiation of training and a voluntary ANSI standard change calling for safer sequential triggers on framing nailers. Injury rates, based on hours of tool use, were calculated yearly. Rates and adjusted rate ratios were calculated with Poisson regression. Attributable risk percent (AR%) and population attributable risk (PAR%) were calculated yearly for modifiable independent risk factors for injury including lack of training in tool use and type of trigger mechanism on tools being used.

RESULTS

As apprentices received training and safer trigger mechanisms became more widespread, injury rates decreased significantly (31%). While school training and hands-on mentoring were both important, injury rates were lowest among apprentices who received both. Although injury rates changed over the observation period, the relative risk comparing trigger mechanisms did not; contact trip triggers consistently carried a twofold risk.

CONCLUSIONS

Although training and safer trigger use both increased, because of the relative prevalence of training and trigger exposures in this population, the engineering solution consistently had the potential to make more difference in population risk. Our findings demonstrate the utility of observational methods including measures of population-based risk in monitoring intervention effectiveness and making recommendations that lead to injury reduction.

How much time is safety worth? A comparison of trigger configurations on pneumatic nail guns in residential framing

OBJECTIVE

Nail gun injuries are among the most common in wood frame construction. Despite evidence that the majority of injuries from unintentional firings could be prevented with a sequential trigger mechanism on the tools, the safer trigger has not been embraced in the fast-paced residential construction industry. An experiment was conducted in an attempt to realistically evaluate the magnitude of productivity concerns.

METHODS

Ten journeymen carpenters built a yard shed on two occasions, using nail guns with two different trigger configurations, alternately, under controlled conditions. Mean differences in time required, nails used, and proper placement were evaluated considering the trigger used and whether the building was the carpenter's first or second project.

RESULTS

The sequential trigger tool required a mean of 10 additional minutes of active nailing time, which represented 10% of mean nailing time (97 minutes) but only 0.77% of the total mean work time (1,298 minutes) to construct each shed. No significant differences were observed in nail count or placement. The majority of the time variability was related to who was using the tool, rather than the type of tool in the person's hand.

CONCLUSIONS

Productivity concerns should focus more on improving the skill of the carpenter rather than on the trigger mechanism. Failure to place tools with the safer trigger configuration, which requires the nose piece to be depressed before the trigger is pulled, in the hands of workers does not make sense given the frequency and potential repercussions of injuries associated with the use of these tools in wood framing.

Retained large nail with perforating injury of the eye

PURPOSE

To report a case of a mixed open globe injury in which a retained large iron nail and perforating injury of the eye coexisted.

METHODS

Case report.

RESULTS

A 26-year-old construction worker was injured by a nail while using a nail gun at work. The iron nail was inadvertently stabbed into the left eye from the upper eyelid and superonasal sclera to temporal sclera, with lens involvement. His visual acuity was counting fingers in the left eye. Primary suture, removal of a retained iron nail, pars plana vitrectomy and lensectomy, and laser photocoagulation were performed. Three months later, an intraocular lens was implanted in the ciliary sulcus. During postoperative 6-month follow-up, final best-corrected visual acuity was 20/20 without complication.

CONCLUSION

We describe one patient with a mixed open globe injury of a retained nail and perforating injury of the eye resulting from a nail gun. As most eye injuries are preventable, proper training of nail-gun operators and use of safety equipment could reduce the incidence of ocular injuries. Expeditious removal of nails and repair of the lacerations can prevent the complications and achieve good final visual outcomes.