Daniel Driscoll, M.D.
Contributing Editor
Ophthalmology was called to the trauma center of the neighboring level one center to evaluate a patient with a reported nail injury to his orbit. Upon arrival, the consult resident found the 50 year old white male in the trauma bay with a small laceration to his right posterotemporal orbit that apparently had been sutured by the referring outside hospital. CT scan revealed an intraorbital nail approximately 58 mm in length just posterior and inferior to the globe. The imaging also showed a substantial quantity of retrobulbar hemorrhage. The patient's vision in the affected eye was approximately count fingers at twelve inches. His left eye saw 20/20 on Snellen testing. Intraocular pressure check by Tono-pen yielded 80 mm of mercury in the affected eye and 12 in the normal eye. Once it was established that the intraocular pressure was substantially elevated, a lateral canthotomy with cantholysis was performed at the bedside. The pressure was reduced to 35 status-post canthotomy, enabling the remainder of the exam to take place. The patient's conjunctiva was substantially chemotic and motility was restricted in all directions of gaze in the right eye. Fundoscopic exam showed normal appearance of the optic nerve without substantial pallor. There were no visible macular striae or commotio retinae apparent.
Neurosurgery was consulted in addition to ophthalmology given the CT appearance of the metal foreign body in the parenchyma of the patient's right frontal lobe. It was determined that a collaborative extraction would be the best choice for the patient, with the oculoplastics service carrying out the actual nail extraction and for neurosurgery to be standing by for any residual complications that could potentially result from an open communication between the brain parenchyma and the exterior of the wound.
Before the extraction, one important question asked of the patient was what activity he had been doing prior to being shot with the nail. According to the patient, he had been using an air nailer to assemble wooden pallets and had somehow accidentally contacted the muzzle end of the nailer while his colleague had been holding it. This information was not only pertinent to know the background of the injury, but also critical for the extraction, as many times pallet nails are manufactured with a spiral pattern to better mitigate slippage from the fastened object(s).
The patient was consented for the procedure which was undertaken at the bedside using intravenous midazolam for sedation and fentanyl for pain control. Two percent lidocaine with 1:100,000 epinephrine was injected into the peri-orbital skin near the areas where the prior sutures had been placed, approximating the location of the buried nail head. The sutures were cut and blunt dissection was used to gain exposure of the nail head, which was abutting the periosteum tightly. Curved hemostats were then placed around the head of the nail and a twisting pattern was undertaken in an attempt to loosen the object from its tract. Unfortunately, the spiral pattern of the shank caused extreme difficulty in freeing the nail the way one would traditionally pull a nail with a claw hammer -- straight out. Instead, the nail had to be backed out against the twist pattern in a counterclockwise fashion, causing a substantial amount of discomfort due to torque on the patient's periosteum. It was decided to then place a retrobulbar block using 4% lidocaine in order to enhance anesthesia. This greatly improved patient comfort and allowed the oculoplastics team to proceed with the counter-clockwise extraction using the curved hemostats. Upon successful removal, the entire nail was inspected to ensure there were no obvious missing fragments that could be lodged in the orbit. The deepest portion of the nail was coated with what appeared to be brain parenchyma, which was sent to pathology for identification. There was no appreciable fluid leakage from the wound site, and copious irrigation of the tract using antibiotic solution was undertaken. The patient was sent for CT scan post-procedurally, which verified absence of any residual foreign body. Neurosurgery requested closure of the wound to prevent open communication with the brain parenchyma. Post-procedure IOP check was 37 and the patient was sent to the neurosurgical ICU for close observation and IV as well as topical antibiotics.
One day post-operative vision remained at one foot finger counting with IOP of 23. One week follow-up yielded normal fundoscopic exam and little improvement in visual acuity. The patient is scheduled to follow-up in approximately one week for continued monitoring.
Figure 1: Sagittal x-ray of nail through orbit.
Figure 2: Coronal x-ray of nail through orbit.
Figure 3: Axial CT showing tip of nail in parenchyma of right frontal lobe.
Figure 4: Axial CT showing head of nail in orbit.
Figure 5: Additional axial CT of nail tip in parenchyma.
Figure 6: Initial view of oversewn wound with underlying nail.
Figure 7: View of exposed nail head.
Figure 8: Zoomed view of exposed nail head.
Figure 9: Surgeon's view during extraction.
Figure 10: Zoomed surgeon's view during extraction.
Figure 11: Attempting to extract with simple anterior traction.
Figure 12: Final extracted nail next to open wound. Note nail tip with presumed brain parenchyma.
Video 1: Difficult nail extraction
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