A 40-year-old male presents with injury to his left hand by a nail gun. While at work, the patient accidentally shot himself with a nail gun. The nail went through pneumatic air hose tubing, his third finger, and his thumb, keeping them all connected. He immediately felt uncomfortable in his left arm, and, upon arrival to the emergency department (ED), complained of swelling in his left arm extending to his neck. He feels shortness of breath and “fullness” in his throat.

HEENT: Normocephalic, atraumatic, conjunctivae clear, tympanic membranes intact, no hemotympanum

Neck: Extensive crepitus bilaterally extending to the mandible

Cardiac: Regular rate and rhythm, first and second heart sounds (S1/S2) faint

Chest wall/Pulmonary: Diffuse crepitus through the entire chest wall, no hematomas, skin intact, equal chest rise, breath sounds faint but equal

Abdominal: No external trauma, non-distended, diffuse crepitus through the entire abdomen extending to pelvis with left crepitus greater than the right

Extremities: Crepitus along the entire left upper extremity, a hemostatic puncture wound to the left thumb and the third digit


Deep sulcus sign, indicating a pneumothorax.

The patient suffered a puncture wound from a nail, which bound his finger to a pneumatic air hose. This continued connection to the air hose resulted in subcutaneous air traveling from his fingers throughout his body. It ultimately resulted in a right-sided pneumothorax and significant crepitus and external tracheal pressure, requiring emergent intubation for airway protection.

Take-Home Points

  • Despite the small and distal initial injury site, high-pressure machinery, such as pneumatic nail guns and paint guns, can cause their medium (air, paint, etc) to move significant distances through the subcutaneous tissue and fascial planes [1].
  • These injuries can cause life-threatening emergencies and warrant emergent surgical consultation [2].


  1. Yazar M,  Gül Z,  Günenç AC,  Yazar SK,  Kozanoğlu E. High pressure paint gun injury of the index finger: a case report. Plast Aesthet Res 2015;2:350-352.
  2. Bekler H, Gokce A, Beyzadeoglu T, Parmaksizoglu F. The surgical treatment and outcomes of high-pressure injection injuries of the hand. J Hand Surg Our 2007 Aug;32(4):394-9. PMID: 17399870

Jillian Merica, MD

Jillian Merica, MD

University of North Carolina Hospital Systems
Jillian Merica, MD

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