Pneumatic Nail Gun Injury to the Cardiac Box: A Case Report of Successful Extraction of a Potentially Dangerous Tool.

Pneumatic nail guns are widely used in industrial and domestic settings and can cause injuries that may appear minor externally but can be potentially life-threatening. While most injuries involve the extremities, penetrations within the cardiac box carry a significant risk of myocardial or great vessel injury and may present with deceptive clinical stability. A 39-year-old male furniture worker presented to the emergency department after an accidental chest injury with a pneumatic nail gun. Despite a potentially hazardous trajectory through the corpus sterni toward the pericardium, the patient remained hemodynamically stable and asymptomatic. Multimodal imaging was performed to evaluate the extent of the injury. A 2-cm, 23-gauge metallic nail was identified in the paracardiac region. Given the high risk of delayed cardiac complications due to the nail's proximity to the pericardium, surgical removal was planned. The foreign body was successfully extracted via a limited sub-sternal incision under local anesthesia and sedation. Intraoperative fluoroscopy was utilized to ensure precise localization of the small-caliber nail and to minimize iatrogenic trauma during extraction. The patient was discharged uneventfully on the first postoperative day. Penetrating injuries to the cardiac box require a high index of clinical suspicion and prompt radiological evaluation, regardless of hemodynamic status. This case demonstrates that minimally invasive, image-guided extraction using intraoperative fluoroscopy can be safely and effectively performed for small-caliber foreign bodies located near the pericardium, enabling precise removal while minimizing procedural risk.