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Nail guns are a ubiquitous tool in the construction industry. They have increased in popularity since their introduction in 1959 as they increase productivity and subsequently reduce costs.[[ 1]] As nail guns have become an essential construction tool, injuries associated with their use are being increasingly recognised.[[2]] The first nail gun injury was reported less than a year after their introduction.[[3]] Since then a large and growing number of case reports and cases series have been published.[[4]]

Nail gun injuries can be divided into intentional and unintentional injuries. The majority of injuries are unintentional and associated with the construction industry. However, a significant number of injuries in consumers have also been reported.[[5,6]] Users with little experience are at the highest risk of unintentional injury, highlighted by a study showing 45% of apprentice carpenters had sustained a nail gun injury in the past year.[[7]] These injuries predominantly affect the extremities and less than 10% require hospital admission.[[8]] Intentional nail gun injuries, although less common than unintentional injuries, are being reported in the literature with increasing frequency.[[9]] Intentional injuries, which are often intracranial, are associated with a good prognosis compared to other intracranial penetrating injuries, due to the low velocity of the nails.[[10]] Concern has been raised that the frequency of injuries is increasing as nail guns continue to become more powerful and more available to the public.[[8,11]]

The aim of this study is to determine the number of patients admitted to Auckland City Hospital (ACH) with a nail gun injury and to understand the factors associated with these admissions. This study’s secondary aim is to review the current Government guidance surrounding nail guns.

Methods

A 25-year retrospective review of patients admitted to ACH with a nail gun injury was performed. The ACH Trauma Registry database, established in 1994, was used to detect all patients admitted with a nail gun injury. The trauma department collects data prospectively on all admitted trauma patients. There were 35,821 patients in the database as of 31 December 2019.

The database was searched by injury description with the keyword’s ‘nail’ and ‘gun’. A retrospective review of the patients identified from this search was then performed to confirm inclusion of only patients admitted to ACH with a nail gun injury. Data prospectively collected in the database pertinent to this study include patients’ demographics, injuries, intention (self-inflicted, unintentional, inflicted by other or unknown), date of injury, location injury occurred, type of transport to hospital, trauma call activation, hospital admitting team, patient occupation, Injury Severity Scores, operations performed, ICU admission, length of stay, discharge destination and patient follow-up.

A second search was performed with the pre-determined registry coding ‘self-inflicted injury’ to determine the number of patients admitted following an intentional injury in the past 25 years. This search captured all patients admitted with an intentional injury, including patients with an injury cause by a nail gun, which allowed for comparison of intentional nail gun injuries with all other intentional injuries. Patient records were retrospectively reviewed and aspects relevant to the circumstances of injury, nature of injury, treatment and outcomes were collected.

Data were entered into IBM SPSS version 25 (Armonk, New York, USA) for analysis. Scale data were tested for normality with a Shapiro-Wilk test. Non-parametric data were tested with a Mann-Whitney U test. Parametrically distributed data were tested using a student t-test. Nominal data were tested using a Chi-squared or Fischer’s exact test. The null hypothesis was rejected if a p-value was <0.05.

New Zealand and Australian legal databases (Westlaw and LexisNexis Advance) and New Zealand legislation were searched to ascertain the law (case law, academic commentary, and legislation) regulating nail guns in New Zealand. The search was extended to include the WorkSafe New Zealand website, Hansard reports and finally Google Scholar for relevant coroners’ reports.

Results

Patient demographics

Forty-five patients were admitted to ACH with a nail gun injury between 1994 and 2019. Two distinct groups were identified: 31% (14) with intentional injuries and 69% (31) with an unintentional workplace injury. As evidenced in Table 1, there was no difference between groups in age (P=0.228) or ethnicity (P=0.607). All patients were male and 91% were working in the construction industry.

Table 1: Patient demographics.

Injury characteristics and admitting team

Table 2 shows unintentional injuries invariably happened at the worksite compared to the 29% of patients with an intentional injury. Home was the most common place for an intentional injury to happen. Eighty-five percent of intentional injuries were to the head, and 80% of unintentional injuries were to an extremity. Patients with an intentional injury were more likely to be admitted to neurosurgery (50%) and ICU (36%), whereas patients with an unintentional injury were primarily admitted to orthopaedics (74%) and the trauma service (16%).

Table 2: Injury characteristics and admitting team.

Injury severity

Table 3 outlines factors associated with injury severity. Patients presenting with intentional injuries had a significantly higher Injury Severity Score (ISS) (24 vs 3), a higher fatality rate (3 vs 0), a higher ICU admission rate (50% vs 3%) and longer length of stay (6.5 vs 1.2 days). ISS is a score that aims to standardise the severity of injuries to predict morbidity and mortality.[[12]] An operation was performed on 79% of patients with an intentional injury and 87% of patients with an unintentional injury. All patients with an unintentional injury were able to be discharged directly home compared with 21% of patients with an intentional injury. Fifty-seven percent of patients with an intentional injury required further care.

Table 3: Injury severity.

Trend in admissions

Figure 1 graphs nail gun admissions divided into five-year periods. Intentional injury admissions did not vary over the 25-year period. Unintentional injuries were low between 1994 to 1998 and have continued at a relatively steady rate since 1999.

Figure 1: Nail gun injury admissions trends.

Comparison of intentional injuries

The second search of the ACH Trauma Registry revealed 575 patients who presented with an intentional injury: 14 (2.4%) of these presented with an injury secondary to a nail gun. The median age was 33 (IQR 23); 416 (72%) were male; 338 (59%) were New Zealand European, 92 (16%) were Māori, 74 (13%) were Pacific Islanders. Overall, injury type was penetrating in 358 (62%), blunt in 216 (38%) and burn in one patient. Cause of injury was stabbing in 320 (56%), fall in 138 (24%), gunshot in 32 (6%), motor vehicle in 27 (5%) and other in 58 (9%). Median length of stay was four days (IQR 8) and there were 54 (9.4%) deaths in total.

Table 4 compares nail gun related intentional injuries to all other intentional injuries. There was no difference in age (P=0.508) or ethnicity (P=0.119). There was a significant difference found in sex (P=0.010) and ISS (P<0.001). Although mortality rate was higher (21% vs 9.4%), it did not reach statistical significance (P=0.136).

Table 4: Comparison of intentional injuries.

Legislation and government guidance

The Health and Safety at Work Act 2015 came into force on 4 April 2016. It was adapted from the Australian Model Work Health and Safety Act, with amendments to reflect the differences between the New Zealand and Australian work environments. Under New Zealand’s previous legislation, the Health and Safety in Employment Act 1992, effective risk management was not enforced and the rising workplace death and injury toll needed to be addressed. A search of New Zealand and Australian legislation produced no results that specifically addressed the use of nail guns. Nail guns are not included in New Zealand’s Arms Act 1983 or its subsequent amendments.[[13]]

Although there is no legislation directly governing the use of nail guns in New Zealand, the Department of Labour (disestablished in 2012) published the Approved code of practice for powder-actuated handheld fastening tools in May 1995. Of note is the emphasis in clause 2.2 on the responsibility of operators to protect themselves and others from hazards associated with nail guns. The code also stipulates the requirement for certification prior to operation of powder-actuated nail guns. An applicant must provide evidence they have “suitable training in the operation of powder-actuated fastening tools and a thorough knowledge of the safe practices relating to that operation.”[[14]] The guidance contained in this code is specific to powder-actuated hand tools. WorkSafe provides a disclaimer signalling that the code has not been updated since its conception despite the new health and safety legislation enacted in 2015. Included in the disclaimer is the intention to progressively review and either update, replace or revoke the guidance.

Although the Health and Safety at Work (General Risk and Workplace Management) Regulations 2016 provide general guidance on identifying hazards and risks and implementing effective control measures, there is nothing current that highlights the dangers that nail guns can present and the importance of certification—certification not being a requirement, as detailed below.

The results from a search of the UK Health and Safety Executive website support concerns regarding nail gun incidents and the risks of intentionally or unintentionally defeating their safety features. This search reinforced the need for workers to be trained prior to operating nail guns. The level of recommended supervision is dependent on the age, experience, ability, and attitude of each worker.[[15]]

There is no requirement that someone must hold a licence before they can hire a nail gun. After the intentional death of a man in the Kāpiti Coast in 2009, Wellington coroner Ian Smith recommended the Government rule that people must be licensed to operate before hiring nail guns.[[16]] There have been no resulting law changes.

A search of Hansard reports, a collection of the official reports of debates in the House of Representatives, again produced no results. It can safely be assumed that to date there have been no discussions in the House of Representatives regarding nail guns. Therefore, it is unlikely legislation will be enacted in the near future.

Discussion

This study revealed two causes of nail gun injury, each with a different effect on injury severity and mortality. Intentional nail gun injuries are associated with more serious injuries and have a higher fatality rate compared to both unintentional nail gun injuries and other means of intentional injury. Nail gun injuries continued to occur at a similar rate throughout the study period.

New Zealand trade workers in the construction industry were responsible for 41,900 work-related Accident Compensation Corporation claims in 2018. This was the highest claim rate by occupation: one in five of all work-related claims.[[17]] Power tool related injury is one of the leading causes of injury in this group.[[18]] It is concerning that there is no legislation that specifically regulates the safe use of nail guns in New Zealand (excluding the Health and Safety at Work Act 2015, which takes a broad approach to health and safety related risks), and a code of practice that was published in 1995 is likely to require review and updating. This code is also only specific to powder-actuated nail guns and has no recommendation for other forms of nail guns.

Nail guns can be divided into high- and low-velocity guns. Powder-actuated nail guns, powered by an explosive charge, are high-velocity and can fire a projectile up to 10cm in length at velocities as high as 1,400 feet per second.[[2]] Low-velocity nail guns traditionally use compressed air, and newer models use combustion or an electric motor to fire the nail.

Given the ongoing occurrences of injuries during the study period, the prevalence of nail guns and the inability to practically enact targeted legislation, New Zealand should publish new guidelines and requirements including:

  • explicit and specific guidance on the safe use of nail guns within the construction industry and domestically (at home)
  • guidance on training, workplace procedures, personal protective equipment, and trigger type (sequential-actuation triggers have been shown to be safer than contact-actuation triggers)
  • certification that takes into consideration the duty imposed by the Health and Safety at Work Act 2015 to minimise risks to workers.[[7]]

A lack of training or safety guidelines on a construction site is likely to be found to be an offence, with WorkSafe New Zealand often taking action regarding training issues. The risk that nail gun injuries occur via domestic use is still very much a real concern. This concern supports the need for certification to be a prerequisite for the purchase of a nail gun.

New Zealand suicide rates continue to rise. The 2018/2019 suicide rate of 13.93 per 100,000 people is the highest recorded in 20 years.[[19]] Suicide in New Zealand disproportionately affects young New Zealanders, which was reflected in the median age of 33 in this study.[[20]] These increasingly high rates led to New Zealand’s first suicide prevention office being opened by the Government within the Ministry of Health. The office’s substantial budget acknowledges the significant work that will need to be undertaken.[[21]] Regulations are needed to target and reduce the high lethality and increased injury severity of intentional nail gun injuries. Interventions should include certification prior to hiring a nail gun, inbuilt safety features that limit firing against skin and safe storage regulations.

This study offers a snapshot into the injury pattern of patients admitted with nail gun injuries. The associated burden of disease is likely significantly underrepresented, as over 90% of injuries do not require admission and are treated in the emergency department.[[8]]

The continued occurrence of unintentional nail gun injuries and the high lethality of intentional injuries represent two areas of concern. There is currently no specific legislation in New Zealand around purchasing, storing, or using nail guns, and only powder-actuated nail guns require certification. Government guidance should be developed with a view to improving safety and reducing the rate of nail gun related injuries.

Summary

Abstract

Aim

To determine the number of patients admitted to Auckland City Hospital (ACH) with a nail gun injury, and to review the current New Zealand legislation surrounding nail guns.

Method

A 25-year retrospective review of patients admitted to ACH with a nail gun injury was performed by searching the ACH Trauma Registry. New Zealand legislation was reviewed.

Results

Between 1994 and 2019, 45 patients were admitted to ACH with a nail gun injury. Two subgroups were identified: 31% with an intentional injury; 69% with an unintentional injury. All patients were male. The mean age was 36.3. Patients with an intentional injury had a higher mortality rate (21.4% vs 9.5%), Injury Severity Scores (24.2 vs 3.4) and ICU admission rate (50% vs 3%) and required more intensive post-injury care when compared to unintentional injuries. There is currently no legislation in New Zealand specifically governing the use of nail guns. Only powder-actuated nail guns require certification.

Conclusion

The continued occurrence of unintentional nail gun injuries and the high lethality of intentional injuries represent two distinct areas of concern. The Government should publish guidance aimed at improving safety and reducing the rate of intentional injury.

Author Information

Matthew J McGuinness: General Surgical Registrar, Whangārei Hospital, New Zealand. Gabrielle Thompson: Senior Solicitor, Henderson Reeves, Whangārei, New Zealand. Samuel Haysom: Medical Student, Trauma Service, Auckland City Hospital, New Zealand. Ian Civil: General and Trauma Surgeon, Trauma Service, Auckland City Hospital, New Zealand.

Acknowledgements

Correspondence

Matthew J McGuinness, General Surgical Registrar, Whangārei Hospital, New Zealand; Auckland City Hospital, 2 Park Road, Grafton, Auckland, New Zealand, 1023; +64 21 038 5481

Correspondence Email

Matt@McGuinness.net.nz

Competing Interests

Nil.

1) Winder MJ, Monteith SJ, Lightfoot N, Mee E. Penetrating head injury from nailguns: a case series from New Zealand. J Clin Neurosci. 2008 Jan;15(1):18-25. doi: 10.1016/j.jocn.2007.06.020. Epub 2007 Nov 26. PMID: 18032048.

2) Pierpont YN, Pappas-Politis E, Naidu DK, Salas RE, Johnson EL, Payne WG. Nail gun injuries to the hand. Eplasty. 2008;8:e52.

3) Murray L. Craniocerebral nail gun injuries: a definitive review of the literature. Brain Inj. 2021 Jan 1:1-9. doi: 10.1080/02699052.2020.1867767. Epub ahead of print. PMID: 33385306.

4) Thoeny AL, Hadaya IA, Lancman BM, Lew V. Hitting the Nail on the Head: A Case Report Demonstrating the Importance of a Multidisciplinary Approach to an Unusual Penetrating Intracranial Injury. A A Case Rep. 2017 Oct 1;9(7):212-215. doi: 10.1213/XAA.0000000000000569. PMID: 28542049.

5) Howard J, Branche CM, & Earnest GS, (2017). The new ANSI nail gun standard: A lost opportunity for safety. Am. J. Ind. Med., 60: 147-151.

6) Lipscomb HJ, Schoenfisch AL. Nail gun injuries treated in U.S emergency departments, 2006-2011: not just a worker safety issue. Am J Ind Med. 2015 Aug;58(8):880-5. doi: 10.1002/ajim.22457. Epub 2015 Apr 27. PMID: 25914335.

7) Lipscomb HJ, Dement JM, Nolan J, Patterson D. 2006. Nail gun injuries in apprentice carpenters: Risk factors and control measures. Am J Ind Med 49(7):505–513.

8) Centers for Disease C, Prevention. Nail gun injuries treated in emergency departments—United States, 2001–2005. MMWR Morb Mortal Wkly Rep. 2007; 56: 329–332.

9) Yuh SJ, Alaqeel A. Ten self-inflicted intracranial penetrating nail gun injuries. Neurosciences (Riyadh). 2015 Jul;20(3):267-70. doi: 10.17712/nsj.2015.3.20150088. PMID: 26166596; PMCID: PMC4710333.

10) Agu CT, Orjiaku ME. Management of a nail impalement injury to the brain in a non-neurosurgical centre: A case report and review of the literature. Int J Surg Case Rep. 2016;19:115-8. doi: 10.1016/j.ijscr.2015.12.035. Epub 2015 Dec 24. PMID: 26745316; PMCID: PMC4756179.

11) Patchana T, Taka TM, Ghanchi H, Wiginton J 4th, Wacker M. Case Report: Projectile Into Right Frontal Lobe From a Nail Gun. Cureus. 2020 Jul 29;12(7):e9460. doi: 10.7759/cureus.9460. PMID: 32874792; PMCID: PMC7455395.

12) Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974 Mar;14(3):187-96. PMID: 4814394.

13) New Zealand Government [Internet]. Arms Legislation Act 2020. 24 June 2020. [cited 2020 Oct 7]. Available from: www. Legislation.govt.nz.

14) WorkSafe [Internet]. Department of Labour. Approved code of practice for powder-actuated handheld fastening tools. Health and safety in employment act of 1992. May 1995. [cited 2020 Oct 7]. Available from: worksafe.govt.nz.

15) Health and Safety Executive [Internet]. Guidance – Nail guns. [cited 2020 Oct 7]. Available from: https://www.hse.gov.uk/woodworking/nail-guns.htm

16) Jones N. License nail gun hires: Coroner. The New Zealand Herald. [cited 2020 Oct 7]. Available from: www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10823978

17) Stats NZ [Internet]. Injury statistics – work related claims: 2018. 02 August 2019. [cited 2020 Oct 7]. Available from: www.stats.govt.nz

18) Level [Internet]. The construction sector is one of the largest employers in New Zealand – it also has a significant proportion of workplace-related illness and accidents. 13 May 2020. [cited 2020 Oct 7]. Available from: http://www.level.org.nz

19) Coronial Services of New Zealand [Internet]. Media Release – 26 August 2019. Office of Chief Coroner of New Zealand. [cited 2020 May 1]. Available from: https://coronialservices.justice.govt.nz/suicide/annual-suicide-statistics-since-2011/

20) Snowdon J. Changes in the age pattern of New Zealand suicide rates. N Z Med J. 2017 Jan 13;130(1448):18-26. PMID: 28081553.

21) Ardern J, Clark D. Suicide prevention office gets down to work. Beehive.govt.nz. [cited 2020 May 1]. Available from: www.beehive.govt.nz/release/suicide-prevention-office-gets-down-work

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Nail guns are a ubiquitous tool in the construction industry. They have increased in popularity since their introduction in 1959 as they increase productivity and subsequently reduce costs.[[ 1]] As nail guns have become an essential construction tool, injuries associated with their use are being increasingly recognised.[[2]] The first nail gun injury was reported less than a year after their introduction.[[3]] Since then a large and growing number of case reports and cases series have been published.[[4]]

Nail gun injuries can be divided into intentional and unintentional injuries. The majority of injuries are unintentional and associated with the construction industry. However, a significant number of injuries in consumers have also been reported.[[5,6]] Users with little experience are at the highest risk of unintentional injury, highlighted by a study showing 45% of apprentice carpenters had sustained a nail gun injury in the past year.[[7]] These injuries predominantly affect the extremities and less than 10% require hospital admission.[[8]] Intentional nail gun injuries, although less common than unintentional injuries, are being reported in the literature with increasing frequency.[[9]] Intentional injuries, which are often intracranial, are associated with a good prognosis compared to other intracranial penetrating injuries, due to the low velocity of the nails.[[10]] Concern has been raised that the frequency of injuries is increasing as nail guns continue to become more powerful and more available to the public.[[8,11]]

The aim of this study is to determine the number of patients admitted to Auckland City Hospital (ACH) with a nail gun injury and to understand the factors associated with these admissions. This study’s secondary aim is to review the current Government guidance surrounding nail guns.

Methods

A 25-year retrospective review of patients admitted to ACH with a nail gun injury was performed. The ACH Trauma Registry database, established in 1994, was used to detect all patients admitted with a nail gun injury. The trauma department collects data prospectively on all admitted trauma patients. There were 35,821 patients in the database as of 31 December 2019.

The database was searched by injury description with the keyword’s ‘nail’ and ‘gun’. A retrospective review of the patients identified from this search was then performed to confirm inclusion of only patients admitted to ACH with a nail gun injury. Data prospectively collected in the database pertinent to this study include patients’ demographics, injuries, intention (self-inflicted, unintentional, inflicted by other or unknown), date of injury, location injury occurred, type of transport to hospital, trauma call activation, hospital admitting team, patient occupation, Injury Severity Scores, operations performed, ICU admission, length of stay, discharge destination and patient follow-up.

A second search was performed with the pre-determined registry coding ‘self-inflicted injury’ to determine the number of patients admitted following an intentional injury in the past 25 years. This search captured all patients admitted with an intentional injury, including patients with an injury cause by a nail gun, which allowed for comparison of intentional nail gun injuries with all other intentional injuries. Patient records were retrospectively reviewed and aspects relevant to the circumstances of injury, nature of injury, treatment and outcomes were collected.

Data were entered into IBM SPSS version 25 (Armonk, New York, USA) for analysis. Scale data were tested for normality with a Shapiro-Wilk test. Non-parametric data were tested with a Mann-Whitney U test. Parametrically distributed data were tested using a student t-test. Nominal data were tested using a Chi-squared or Fischer’s exact test. The null hypothesis was rejected if a p-value was <0.05.

New Zealand and Australian legal databases (Westlaw and LexisNexis Advance) and New Zealand legislation were searched to ascertain the law (case law, academic commentary, and legislation) regulating nail guns in New Zealand. The search was extended to include the WorkSafe New Zealand website, Hansard reports and finally Google Scholar for relevant coroners’ reports.

Results

Patient demographics

Forty-five patients were admitted to ACH with a nail gun injury between 1994 and 2019. Two distinct groups were identified: 31% (14) with intentional injuries and 69% (31) with an unintentional workplace injury. As evidenced in Table 1, there was no difference between groups in age (P=0.228) or ethnicity (P=0.607). All patients were male and 91% were working in the construction industry.

Table 1: Patient demographics.

Injury characteristics and admitting team

Table 2 shows unintentional injuries invariably happened at the worksite compared to the 29% of patients with an intentional injury. Home was the most common place for an intentional injury to happen. Eighty-five percent of intentional injuries were to the head, and 80% of unintentional injuries were to an extremity. Patients with an intentional injury were more likely to be admitted to neurosurgery (50%) and ICU (36%), whereas patients with an unintentional injury were primarily admitted to orthopaedics (74%) and the trauma service (16%).

Table 2: Injury characteristics and admitting team.

Injury severity

Table 3 outlines factors associated with injury severity. Patients presenting with intentional injuries had a significantly higher Injury Severity Score (ISS) (24 vs 3), a higher fatality rate (3 vs 0), a higher ICU admission rate (50% vs 3%) and longer length of stay (6.5 vs 1.2 days). ISS is a score that aims to standardise the severity of injuries to predict morbidity and mortality.[[12]] An operation was performed on 79% of patients with an intentional injury and 87% of patients with an unintentional injury. All patients with an unintentional injury were able to be discharged directly home compared with 21% of patients with an intentional injury. Fifty-seven percent of patients with an intentional injury required further care.

Table 3: Injury severity.

Trend in admissions

Figure 1 graphs nail gun admissions divided into five-year periods. Intentional injury admissions did not vary over the 25-year period. Unintentional injuries were low between 1994 to 1998 and have continued at a relatively steady rate since 1999.

Figure 1: Nail gun injury admissions trends.

Comparison of intentional injuries

The second search of the ACH Trauma Registry revealed 575 patients who presented with an intentional injury: 14 (2.4%) of these presented with an injury secondary to a nail gun. The median age was 33 (IQR 23); 416 (72%) were male; 338 (59%) were New Zealand European, 92 (16%) were Māori, 74 (13%) were Pacific Islanders. Overall, injury type was penetrating in 358 (62%), blunt in 216 (38%) and burn in one patient. Cause of injury was stabbing in 320 (56%), fall in 138 (24%), gunshot in 32 (6%), motor vehicle in 27 (5%) and other in 58 (9%). Median length of stay was four days (IQR 8) and there were 54 (9.4%) deaths in total.

Table 4 compares nail gun related intentional injuries to all other intentional injuries. There was no difference in age (P=0.508) or ethnicity (P=0.119). There was a significant difference found in sex (P=0.010) and ISS (P<0.001). Although mortality rate was higher (21% vs 9.4%), it did not reach statistical significance (P=0.136).

Table 4: Comparison of intentional injuries.

Legislation and government guidance

The Health and Safety at Work Act 2015 came into force on 4 April 2016. It was adapted from the Australian Model Work Health and Safety Act, with amendments to reflect the differences between the New Zealand and Australian work environments. Under New Zealand’s previous legislation, the Health and Safety in Employment Act 1992, effective risk management was not enforced and the rising workplace death and injury toll needed to be addressed. A search of New Zealand and Australian legislation produced no results that specifically addressed the use of nail guns. Nail guns are not included in New Zealand’s Arms Act 1983 or its subsequent amendments.[[13]]

Although there is no legislation directly governing the use of nail guns in New Zealand, the Department of Labour (disestablished in 2012) published the Approved code of practice for powder-actuated handheld fastening tools in May 1995. Of note is the emphasis in clause 2.2 on the responsibility of operators to protect themselves and others from hazards associated with nail guns. The code also stipulates the requirement for certification prior to operation of powder-actuated nail guns. An applicant must provide evidence they have “suitable training in the operation of powder-actuated fastening tools and a thorough knowledge of the safe practices relating to that operation.”[[14]] The guidance contained in this code is specific to powder-actuated hand tools. WorkSafe provides a disclaimer signalling that the code has not been updated since its conception despite the new health and safety legislation enacted in 2015. Included in the disclaimer is the intention to progressively review and either update, replace or revoke the guidance.

Although the Health and Safety at Work (General Risk and Workplace Management) Regulations 2016 provide general guidance on identifying hazards and risks and implementing effective control measures, there is nothing current that highlights the dangers that nail guns can present and the importance of certification—certification not being a requirement, as detailed below.

The results from a search of the UK Health and Safety Executive website support concerns regarding nail gun incidents and the risks of intentionally or unintentionally defeating their safety features. This search reinforced the need for workers to be trained prior to operating nail guns. The level of recommended supervision is dependent on the age, experience, ability, and attitude of each worker.[[15]]

There is no requirement that someone must hold a licence before they can hire a nail gun. After the intentional death of a man in the Kāpiti Coast in 2009, Wellington coroner Ian Smith recommended the Government rule that people must be licensed to operate before hiring nail guns.[[16]] There have been no resulting law changes.

A search of Hansard reports, a collection of the official reports of debates in the House of Representatives, again produced no results. It can safely be assumed that to date there have been no discussions in the House of Representatives regarding nail guns. Therefore, it is unlikely legislation will be enacted in the near future.

Discussion

This study revealed two causes of nail gun injury, each with a different effect on injury severity and mortality. Intentional nail gun injuries are associated with more serious injuries and have a higher fatality rate compared to both unintentional nail gun injuries and other means of intentional injury. Nail gun injuries continued to occur at a similar rate throughout the study period.

New Zealand trade workers in the construction industry were responsible for 41,900 work-related Accident Compensation Corporation claims in 2018. This was the highest claim rate by occupation: one in five of all work-related claims.[[17]] Power tool related injury is one of the leading causes of injury in this group.[[18]] It is concerning that there is no legislation that specifically regulates the safe use of nail guns in New Zealand (excluding the Health and Safety at Work Act 2015, which takes a broad approach to health and safety related risks), and a code of practice that was published in 1995 is likely to require review and updating. This code is also only specific to powder-actuated nail guns and has no recommendation for other forms of nail guns.

Nail guns can be divided into high- and low-velocity guns. Powder-actuated nail guns, powered by an explosive charge, are high-velocity and can fire a projectile up to 10cm in length at velocities as high as 1,400 feet per second.[[2]] Low-velocity nail guns traditionally use compressed air, and newer models use combustion or an electric motor to fire the nail.

Given the ongoing occurrences of injuries during the study period, the prevalence of nail guns and the inability to practically enact targeted legislation, New Zealand should publish new guidelines and requirements including:

  • explicit and specific guidance on the safe use of nail guns within the construction industry and domestically (at home)
  • guidance on training, workplace procedures, personal protective equipment, and trigger type (sequential-actuation triggers have been shown to be safer than contact-actuation triggers)
  • certification that takes into consideration the duty imposed by the Health and Safety at Work Act 2015 to minimise risks to workers.[[7]]

A lack of training or safety guidelines on a construction site is likely to be found to be an offence, with WorkSafe New Zealand often taking action regarding training issues. The risk that nail gun injuries occur via domestic use is still very much a real concern. This concern supports the need for certification to be a prerequisite for the purchase of a nail gun.

New Zealand suicide rates continue to rise. The 2018/2019 suicide rate of 13.93 per 100,000 people is the highest recorded in 20 years.[[19]] Suicide in New Zealand disproportionately affects young New Zealanders, which was reflected in the median age of 33 in this study.[[20]] These increasingly high rates led to New Zealand’s first suicide prevention office being opened by the Government within the Ministry of Health. The office’s substantial budget acknowledges the significant work that will need to be undertaken.[[21]] Regulations are needed to target and reduce the high lethality and increased injury severity of intentional nail gun injuries. Interventions should include certification prior to hiring a nail gun, inbuilt safety features that limit firing against skin and safe storage regulations.

This study offers a snapshot into the injury pattern of patients admitted with nail gun injuries. The associated burden of disease is likely significantly underrepresented, as over 90% of injuries do not require admission and are treated in the emergency department.[[8]]

The continued occurrence of unintentional nail gun injuries and the high lethality of intentional injuries represent two areas of concern. There is currently no specific legislation in New Zealand around purchasing, storing, or using nail guns, and only powder-actuated nail guns require certification. Government guidance should be developed with a view to improving safety and reducing the rate of nail gun related injuries.

Summary

Abstract

Aim

To determine the number of patients admitted to Auckland City Hospital (ACH) with a nail gun injury, and to review the current New Zealand legislation surrounding nail guns.

Method

A 25-year retrospective review of patients admitted to ACH with a nail gun injury was performed by searching the ACH Trauma Registry. New Zealand legislation was reviewed.

Results

Between 1994 and 2019, 45 patients were admitted to ACH with a nail gun injury. Two subgroups were identified: 31% with an intentional injury; 69% with an unintentional injury. All patients were male. The mean age was 36.3. Patients with an intentional injury had a higher mortality rate (21.4% vs 9.5%), Injury Severity Scores (24.2 vs 3.4) and ICU admission rate (50% vs 3%) and required more intensive post-injury care when compared to unintentional injuries. There is currently no legislation in New Zealand specifically governing the use of nail guns. Only powder-actuated nail guns require certification.

Conclusion

The continued occurrence of unintentional nail gun injuries and the high lethality of intentional injuries represent two distinct areas of concern. The Government should publish guidance aimed at improving safety and reducing the rate of intentional injury.

Author Information

Matthew J McGuinness: General Surgical Registrar, Whangārei Hospital, New Zealand. Gabrielle Thompson: Senior Solicitor, Henderson Reeves, Whangārei, New Zealand. Samuel Haysom: Medical Student, Trauma Service, Auckland City Hospital, New Zealand. Ian Civil: General and Trauma Surgeon, Trauma Service, Auckland City Hospital, New Zealand.

Acknowledgements

Correspondence

Matthew J McGuinness, General Surgical Registrar, Whangārei Hospital, New Zealand; Auckland City Hospital, 2 Park Road, Grafton, Auckland, New Zealand, 1023; +64 21 038 5481

Correspondence Email

Matt@McGuinness.net.nz

Competing Interests

Nil.

1) Winder MJ, Monteith SJ, Lightfoot N, Mee E. Penetrating head injury from nailguns: a case series from New Zealand. J Clin Neurosci. 2008 Jan;15(1):18-25. doi: 10.1016/j.jocn.2007.06.020. Epub 2007 Nov 26. PMID: 18032048.

2) Pierpont YN, Pappas-Politis E, Naidu DK, Salas RE, Johnson EL, Payne WG. Nail gun injuries to the hand. Eplasty. 2008;8:e52.

3) Murray L. Craniocerebral nail gun injuries: a definitive review of the literature. Brain Inj. 2021 Jan 1:1-9. doi: 10.1080/02699052.2020.1867767. Epub ahead of print. PMID: 33385306.

4) Thoeny AL, Hadaya IA, Lancman BM, Lew V. Hitting the Nail on the Head: A Case Report Demonstrating the Importance of a Multidisciplinary Approach to an Unusual Penetrating Intracranial Injury. A A Case Rep. 2017 Oct 1;9(7):212-215. doi: 10.1213/XAA.0000000000000569. PMID: 28542049.

5) Howard J, Branche CM, & Earnest GS, (2017). The new ANSI nail gun standard: A lost opportunity for safety. Am. J. Ind. Med., 60: 147-151.

6) Lipscomb HJ, Schoenfisch AL. Nail gun injuries treated in U.S emergency departments, 2006-2011: not just a worker safety issue. Am J Ind Med. 2015 Aug;58(8):880-5. doi: 10.1002/ajim.22457. Epub 2015 Apr 27. PMID: 25914335.

7) Lipscomb HJ, Dement JM, Nolan J, Patterson D. 2006. Nail gun injuries in apprentice carpenters: Risk factors and control measures. Am J Ind Med 49(7):505–513.

8) Centers for Disease C, Prevention. Nail gun injuries treated in emergency departments—United States, 2001–2005. MMWR Morb Mortal Wkly Rep. 2007; 56: 329–332.

9) Yuh SJ, Alaqeel A. Ten self-inflicted intracranial penetrating nail gun injuries. Neurosciences (Riyadh). 2015 Jul;20(3):267-70. doi: 10.17712/nsj.2015.3.20150088. PMID: 26166596; PMCID: PMC4710333.

10) Agu CT, Orjiaku ME. Management of a nail impalement injury to the brain in a non-neurosurgical centre: A case report and review of the literature. Int J Surg Case Rep. 2016;19:115-8. doi: 10.1016/j.ijscr.2015.12.035. Epub 2015 Dec 24. PMID: 26745316; PMCID: PMC4756179.

11) Patchana T, Taka TM, Ghanchi H, Wiginton J 4th, Wacker M. Case Report: Projectile Into Right Frontal Lobe From a Nail Gun. Cureus. 2020 Jul 29;12(7):e9460. doi: 10.7759/cureus.9460. PMID: 32874792; PMCID: PMC7455395.

12) Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974 Mar;14(3):187-96. PMID: 4814394.

13) New Zealand Government [Internet]. Arms Legislation Act 2020. 24 June 2020. [cited 2020 Oct 7]. Available from: www. Legislation.govt.nz.

14) WorkSafe [Internet]. Department of Labour. Approved code of practice for powder-actuated handheld fastening tools. Health and safety in employment act of 1992. May 1995. [cited 2020 Oct 7]. Available from: worksafe.govt.nz.

15) Health and Safety Executive [Internet]. Guidance – Nail guns. [cited 2020 Oct 7]. Available from: https://www.hse.gov.uk/woodworking/nail-guns.htm

16) Jones N. License nail gun hires: Coroner. The New Zealand Herald. [cited 2020 Oct 7]. Available from: www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10823978

17) Stats NZ [Internet]. Injury statistics – work related claims: 2018. 02 August 2019. [cited 2020 Oct 7]. Available from: www.stats.govt.nz

18) Level [Internet]. The construction sector is one of the largest employers in New Zealand – it also has a significant proportion of workplace-related illness and accidents. 13 May 2020. [cited 2020 Oct 7]. Available from: http://www.level.org.nz

19) Coronial Services of New Zealand [Internet]. Media Release – 26 August 2019. Office of Chief Coroner of New Zealand. [cited 2020 May 1]. Available from: https://coronialservices.justice.govt.nz/suicide/annual-suicide-statistics-since-2011/

20) Snowdon J. Changes in the age pattern of New Zealand suicide rates. N Z Med J. 2017 Jan 13;130(1448):18-26. PMID: 28081553.

21) Ardern J, Clark D. Suicide prevention office gets down to work. Beehive.govt.nz. [cited 2020 May 1]. Available from: www.beehive.govt.nz/release/suicide-prevention-office-gets-down-work

For the PDF of this article,
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Nail guns are a ubiquitous tool in the construction industry. They have increased in popularity since their introduction in 1959 as they increase productivity and subsequently reduce costs.[[ 1]] As nail guns have become an essential construction tool, injuries associated with their use are being increasingly recognised.[[2]] The first nail gun injury was reported less than a year after their introduction.[[3]] Since then a large and growing number of case reports and cases series have been published.[[4]]

Nail gun injuries can be divided into intentional and unintentional injuries. The majority of injuries are unintentional and associated with the construction industry. However, a significant number of injuries in consumers have also been reported.[[5,6]] Users with little experience are at the highest risk of unintentional injury, highlighted by a study showing 45% of apprentice carpenters had sustained a nail gun injury in the past year.[[7]] These injuries predominantly affect the extremities and less than 10% require hospital admission.[[8]] Intentional nail gun injuries, although less common than unintentional injuries, are being reported in the literature with increasing frequency.[[9]] Intentional injuries, which are often intracranial, are associated with a good prognosis compared to other intracranial penetrating injuries, due to the low velocity of the nails.[[10]] Concern has been raised that the frequency of injuries is increasing as nail guns continue to become more powerful and more available to the public.[[8,11]]

The aim of this study is to determine the number of patients admitted to Auckland City Hospital (ACH) with a nail gun injury and to understand the factors associated with these admissions. This study’s secondary aim is to review the current Government guidance surrounding nail guns.

Methods

A 25-year retrospective review of patients admitted to ACH with a nail gun injury was performed. The ACH Trauma Registry database, established in 1994, was used to detect all patients admitted with a nail gun injury. The trauma department collects data prospectively on all admitted trauma patients. There were 35,821 patients in the database as of 31 December 2019.

The database was searched by injury description with the keyword’s ‘nail’ and ‘gun’. A retrospective review of the patients identified from this search was then performed to confirm inclusion of only patients admitted to ACH with a nail gun injury. Data prospectively collected in the database pertinent to this study include patients’ demographics, injuries, intention (self-inflicted, unintentional, inflicted by other or unknown), date of injury, location injury occurred, type of transport to hospital, trauma call activation, hospital admitting team, patient occupation, Injury Severity Scores, operations performed, ICU admission, length of stay, discharge destination and patient follow-up.

A second search was performed with the pre-determined registry coding ‘self-inflicted injury’ to determine the number of patients admitted following an intentional injury in the past 25 years. This search captured all patients admitted with an intentional injury, including patients with an injury cause by a nail gun, which allowed for comparison of intentional nail gun injuries with all other intentional injuries. Patient records were retrospectively reviewed and aspects relevant to the circumstances of injury, nature of injury, treatment and outcomes were collected.

Data were entered into IBM SPSS version 25 (Armonk, New York, USA) for analysis. Scale data were tested for normality with a Shapiro-Wilk test. Non-parametric data were tested with a Mann-Whitney U test. Parametrically distributed data were tested using a student t-test. Nominal data were tested using a Chi-squared or Fischer’s exact test. The null hypothesis was rejected if a p-value was <0.05.

New Zealand and Australian legal databases (Westlaw and LexisNexis Advance) and New Zealand legislation were searched to ascertain the law (case law, academic commentary, and legislation) regulating nail guns in New Zealand. The search was extended to include the WorkSafe New Zealand website, Hansard reports and finally Google Scholar for relevant coroners’ reports.

Results

Patient demographics

Forty-five patients were admitted to ACH with a nail gun injury between 1994 and 2019. Two distinct groups were identified: 31% (14) with intentional injuries and 69% (31) with an unintentional workplace injury. As evidenced in Table 1, there was no difference between groups in age (P=0.228) or ethnicity (P=0.607). All patients were male and 91% were working in the construction industry.

Table 1: Patient demographics.

Injury characteristics and admitting team

Table 2 shows unintentional injuries invariably happened at the worksite compared to the 29% of patients with an intentional injury. Home was the most common place for an intentional injury to happen. Eighty-five percent of intentional injuries were to the head, and 80% of unintentional injuries were to an extremity. Patients with an intentional injury were more likely to be admitted to neurosurgery (50%) and ICU (36%), whereas patients with an unintentional injury were primarily admitted to orthopaedics (74%) and the trauma service (16%).

Table 2: Injury characteristics and admitting team.

Injury severity

Table 3 outlines factors associated with injury severity. Patients presenting with intentional injuries had a significantly higher Injury Severity Score (ISS) (24 vs 3), a higher fatality rate (3 vs 0), a higher ICU admission rate (50% vs 3%) and longer length of stay (6.5 vs 1.2 days). ISS is a score that aims to standardise the severity of injuries to predict morbidity and mortality.[[12]] An operation was performed on 79% of patients with an intentional injury and 87% of patients with an unintentional injury. All patients with an unintentional injury were able to be discharged directly home compared with 21% of patients with an intentional injury. Fifty-seven percent of patients with an intentional injury required further care.

Table 3: Injury severity.

Trend in admissions

Figure 1 graphs nail gun admissions divided into five-year periods. Intentional injury admissions did not vary over the 25-year period. Unintentional injuries were low between 1994 to 1998 and have continued at a relatively steady rate since 1999.

Figure 1: Nail gun injury admissions trends.

Comparison of intentional injuries

The second search of the ACH Trauma Registry revealed 575 patients who presented with an intentional injury: 14 (2.4%) of these presented with an injury secondary to a nail gun. The median age was 33 (IQR 23); 416 (72%) were male; 338 (59%) were New Zealand European, 92 (16%) were Māori, 74 (13%) were Pacific Islanders. Overall, injury type was penetrating in 358 (62%), blunt in 216 (38%) and burn in one patient. Cause of injury was stabbing in 320 (56%), fall in 138 (24%), gunshot in 32 (6%), motor vehicle in 27 (5%) and other in 58 (9%). Median length of stay was four days (IQR 8) and there were 54 (9.4%) deaths in total.

Table 4 compares nail gun related intentional injuries to all other intentional injuries. There was no difference in age (P=0.508) or ethnicity (P=0.119). There was a significant difference found in sex (P=0.010) and ISS (P<0.001). Although mortality rate was higher (21% vs 9.4%), it did not reach statistical significance (P=0.136).

Table 4: Comparison of intentional injuries.

Legislation and government guidance

The Health and Safety at Work Act 2015 came into force on 4 April 2016. It was adapted from the Australian Model Work Health and Safety Act, with amendments to reflect the differences between the New Zealand and Australian work environments. Under New Zealand’s previous legislation, the Health and Safety in Employment Act 1992, effective risk management was not enforced and the rising workplace death and injury toll needed to be addressed. A search of New Zealand and Australian legislation produced no results that specifically addressed the use of nail guns. Nail guns are not included in New Zealand’s Arms Act 1983 or its subsequent amendments.[[13]]

Although there is no legislation directly governing the use of nail guns in New Zealand, the Department of Labour (disestablished in 2012) published the Approved code of practice for powder-actuated handheld fastening tools in May 1995. Of note is the emphasis in clause 2.2 on the responsibility of operators to protect themselves and others from hazards associated with nail guns. The code also stipulates the requirement for certification prior to operation of powder-actuated nail guns. An applicant must provide evidence they have “suitable training in the operation of powder-actuated fastening tools and a thorough knowledge of the safe practices relating to that operation.”[[14]] The guidance contained in this code is specific to powder-actuated hand tools. WorkSafe provides a disclaimer signalling that the code has not been updated since its conception despite the new health and safety legislation enacted in 2015. Included in the disclaimer is the intention to progressively review and either update, replace or revoke the guidance.

Although the Health and Safety at Work (General Risk and Workplace Management) Regulations 2016 provide general guidance on identifying hazards and risks and implementing effective control measures, there is nothing current that highlights the dangers that nail guns can present and the importance of certification—certification not being a requirement, as detailed below.

The results from a search of the UK Health and Safety Executive website support concerns regarding nail gun incidents and the risks of intentionally or unintentionally defeating their safety features. This search reinforced the need for workers to be trained prior to operating nail guns. The level of recommended supervision is dependent on the age, experience, ability, and attitude of each worker.[[15]]

There is no requirement that someone must hold a licence before they can hire a nail gun. After the intentional death of a man in the Kāpiti Coast in 2009, Wellington coroner Ian Smith recommended the Government rule that people must be licensed to operate before hiring nail guns.[[16]] There have been no resulting law changes.

A search of Hansard reports, a collection of the official reports of debates in the House of Representatives, again produced no results. It can safely be assumed that to date there have been no discussions in the House of Representatives regarding nail guns. Therefore, it is unlikely legislation will be enacted in the near future.

Discussion

This study revealed two causes of nail gun injury, each with a different effect on injury severity and mortality. Intentional nail gun injuries are associated with more serious injuries and have a higher fatality rate compared to both unintentional nail gun injuries and other means of intentional injury. Nail gun injuries continued to occur at a similar rate throughout the study period.

New Zealand trade workers in the construction industry were responsible for 41,900 work-related Accident Compensation Corporation claims in 2018. This was the highest claim rate by occupation: one in five of all work-related claims.[[17]] Power tool related injury is one of the leading causes of injury in this group.[[18]] It is concerning that there is no legislation that specifically regulates the safe use of nail guns in New Zealand (excluding the Health and Safety at Work Act 2015, which takes a broad approach to health and safety related risks), and a code of practice that was published in 1995 is likely to require review and updating. This code is also only specific to powder-actuated nail guns and has no recommendation for other forms of nail guns.

Nail guns can be divided into high- and low-velocity guns. Powder-actuated nail guns, powered by an explosive charge, are high-velocity and can fire a projectile up to 10cm in length at velocities as high as 1,400 feet per second.[[2]] Low-velocity nail guns traditionally use compressed air, and newer models use combustion or an electric motor to fire the nail.

Given the ongoing occurrences of injuries during the study period, the prevalence of nail guns and the inability to practically enact targeted legislation, New Zealand should publish new guidelines and requirements including:

  • explicit and specific guidance on the safe use of nail guns within the construction industry and domestically (at home)
  • guidance on training, workplace procedures, personal protective equipment, and trigger type (sequential-actuation triggers have been shown to be safer than contact-actuation triggers)
  • certification that takes into consideration the duty imposed by the Health and Safety at Work Act 2015 to minimise risks to workers.[[7]]

A lack of training or safety guidelines on a construction site is likely to be found to be an offence, with WorkSafe New Zealand often taking action regarding training issues. The risk that nail gun injuries occur via domestic use is still very much a real concern. This concern supports the need for certification to be a prerequisite for the purchase of a nail gun.

New Zealand suicide rates continue to rise. The 2018/2019 suicide rate of 13.93 per 100,000 people is the highest recorded in 20 years.[[19]] Suicide in New Zealand disproportionately affects young New Zealanders, which was reflected in the median age of 33 in this study.[[20]] These increasingly high rates led to New Zealand’s first suicide prevention office being opened by the Government within the Ministry of Health. The office’s substantial budget acknowledges the significant work that will need to be undertaken.[[21]] Regulations are needed to target and reduce the high lethality and increased injury severity of intentional nail gun injuries. Interventions should include certification prior to hiring a nail gun, inbuilt safety features that limit firing against skin and safe storage regulations.

This study offers a snapshot into the injury pattern of patients admitted with nail gun injuries. The associated burden of disease is likely significantly underrepresented, as over 90% of injuries do not require admission and are treated in the emergency department.[[8]]

The continued occurrence of unintentional nail gun injuries and the high lethality of intentional injuries represent two areas of concern. There is currently no specific legislation in New Zealand around purchasing, storing, or using nail guns, and only powder-actuated nail guns require certification. Government guidance should be developed with a view to improving safety and reducing the rate of nail gun related injuries.

Summary

Abstract

Aim

To determine the number of patients admitted to Auckland City Hospital (ACH) with a nail gun injury, and to review the current New Zealand legislation surrounding nail guns.

Method

A 25-year retrospective review of patients admitted to ACH with a nail gun injury was performed by searching the ACH Trauma Registry. New Zealand legislation was reviewed.

Results

Between 1994 and 2019, 45 patients were admitted to ACH with a nail gun injury. Two subgroups were identified: 31% with an intentional injury; 69% with an unintentional injury. All patients were male. The mean age was 36.3. Patients with an intentional injury had a higher mortality rate (21.4% vs 9.5%), Injury Severity Scores (24.2 vs 3.4) and ICU admission rate (50% vs 3%) and required more intensive post-injury care when compared to unintentional injuries. There is currently no legislation in New Zealand specifically governing the use of nail guns. Only powder-actuated nail guns require certification.

Conclusion

The continued occurrence of unintentional nail gun injuries and the high lethality of intentional injuries represent two distinct areas of concern. The Government should publish guidance aimed at improving safety and reducing the rate of intentional injury.

Author Information

Matthew J McGuinness: General Surgical Registrar, Whangārei Hospital, New Zealand. Gabrielle Thompson: Senior Solicitor, Henderson Reeves, Whangārei, New Zealand. Samuel Haysom: Medical Student, Trauma Service, Auckland City Hospital, New Zealand. Ian Civil: General and Trauma Surgeon, Trauma Service, Auckland City Hospital, New Zealand.

Acknowledgements

Correspondence

Matthew J McGuinness, General Surgical Registrar, Whangārei Hospital, New Zealand; Auckland City Hospital, 2 Park Road, Grafton, Auckland, New Zealand, 1023; +64 21 038 5481

Correspondence Email

Matt@McGuinness.net.nz

Competing Interests

Nil.

1) Winder MJ, Monteith SJ, Lightfoot N, Mee E. Penetrating head injury from nailguns: a case series from New Zealand. J Clin Neurosci. 2008 Jan;15(1):18-25. doi: 10.1016/j.jocn.2007.06.020. Epub 2007 Nov 26. PMID: 18032048.

2) Pierpont YN, Pappas-Politis E, Naidu DK, Salas RE, Johnson EL, Payne WG. Nail gun injuries to the hand. Eplasty. 2008;8:e52.

3) Murray L. Craniocerebral nail gun injuries: a definitive review of the literature. Brain Inj. 2021 Jan 1:1-9. doi: 10.1080/02699052.2020.1867767. Epub ahead of print. PMID: 33385306.

4) Thoeny AL, Hadaya IA, Lancman BM, Lew V. Hitting the Nail on the Head: A Case Report Demonstrating the Importance of a Multidisciplinary Approach to an Unusual Penetrating Intracranial Injury. A A Case Rep. 2017 Oct 1;9(7):212-215. doi: 10.1213/XAA.0000000000000569. PMID: 28542049.

5) Howard J, Branche CM, & Earnest GS, (2017). The new ANSI nail gun standard: A lost opportunity for safety. Am. J. Ind. Med., 60: 147-151.

6) Lipscomb HJ, Schoenfisch AL. Nail gun injuries treated in U.S emergency departments, 2006-2011: not just a worker safety issue. Am J Ind Med. 2015 Aug;58(8):880-5. doi: 10.1002/ajim.22457. Epub 2015 Apr 27. PMID: 25914335.

7) Lipscomb HJ, Dement JM, Nolan J, Patterson D. 2006. Nail gun injuries in apprentice carpenters: Risk factors and control measures. Am J Ind Med 49(7):505–513.

8) Centers for Disease C, Prevention. Nail gun injuries treated in emergency departments—United States, 2001–2005. MMWR Morb Mortal Wkly Rep. 2007; 56: 329–332.

9) Yuh SJ, Alaqeel A. Ten self-inflicted intracranial penetrating nail gun injuries. Neurosciences (Riyadh). 2015 Jul;20(3):267-70. doi: 10.17712/nsj.2015.3.20150088. PMID: 26166596; PMCID: PMC4710333.

10) Agu CT, Orjiaku ME. Management of a nail impalement injury to the brain in a non-neurosurgical centre: A case report and review of the literature. Int J Surg Case Rep. 2016;19:115-8. doi: 10.1016/j.ijscr.2015.12.035. Epub 2015 Dec 24. PMID: 26745316; PMCID: PMC4756179.

11) Patchana T, Taka TM, Ghanchi H, Wiginton J 4th, Wacker M. Case Report: Projectile Into Right Frontal Lobe From a Nail Gun. Cureus. 2020 Jul 29;12(7):e9460. doi: 10.7759/cureus.9460. PMID: 32874792; PMCID: PMC7455395.

12) Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974 Mar;14(3):187-96. PMID: 4814394.

13) New Zealand Government [Internet]. Arms Legislation Act 2020. 24 June 2020. [cited 2020 Oct 7]. Available from: www. Legislation.govt.nz.

14) WorkSafe [Internet]. Department of Labour. Approved code of practice for powder-actuated handheld fastening tools. Health and safety in employment act of 1992. May 1995. [cited 2020 Oct 7]. Available from: worksafe.govt.nz.

15) Health and Safety Executive [Internet]. Guidance – Nail guns. [cited 2020 Oct 7]. Available from: https://www.hse.gov.uk/woodworking/nail-guns.htm

16) Jones N. License nail gun hires: Coroner. The New Zealand Herald. [cited 2020 Oct 7]. Available from: www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10823978

17) Stats NZ [Internet]. Injury statistics – work related claims: 2018. 02 August 2019. [cited 2020 Oct 7]. Available from: www.stats.govt.nz

18) Level [Internet]. The construction sector is one of the largest employers in New Zealand – it also has a significant proportion of workplace-related illness and accidents. 13 May 2020. [cited 2020 Oct 7]. Available from: http://www.level.org.nz

19) Coronial Services of New Zealand [Internet]. Media Release – 26 August 2019. Office of Chief Coroner of New Zealand. [cited 2020 May 1]. Available from: https://coronialservices.justice.govt.nz/suicide/annual-suicide-statistics-since-2011/

20) Snowdon J. Changes in the age pattern of New Zealand suicide rates. N Z Med J. 2017 Jan 13;130(1448):18-26. PMID: 28081553.

21) Ardern J, Clark D. Suicide prevention office gets down to work. Beehive.govt.nz. [cited 2020 May 1]. Available from: www.beehive.govt.nz/release/suicide-prevention-office-gets-down-work

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