|Year : 2013 | Volume
| Issue : 2 | Page : 85-87
Nail in the heart of a 4-year-old Nigerian girl
Ibrahim Aliyu1, Ismail M Inuwa2
1 Department of Paediatrics, Cardiothoracic Unit, Aminu Kano Teaching Hospital/Bayero University Kano, Kano, Nigeria
2 Department of Surgery, Cardiothoracic Unit, Aminu Kano Teaching Hospital/Bayero University Kano, Kano, Nigeria
|Date of Web Publication||13-Feb-2014|
Department of Paediatrics, Aminu Kano Teaching Hospital/Bayero University Kano, Kano
Source of Support: None, Conflict of Interest: None
Children are very active and explorational, some of the plays they engage in occasionally put them in harm's way. Common problems often encountered especially in those less than 3 years are cases of foreign body aspiration and ingestion. However, we report a case of traumatic chest penetrating nail injury with penetration of the right ventricle in a 4-year-old Nigerian girl; who was fortunate to have survived following successfully surgical extraction of the nail.
Keywords: Child, heart, nail, penetration, surgery, trauma
|How to cite this article:|
Aliyu I, Inuwa IM. Nail in the heart of a 4-year-old Nigerian girl. Nig J Cardiol 2013;10:85-7
| Introduction|| |
Healthy children are usually active, playful, and explorational which at times puts them in harm's way; this coupled with their tendency to mouth objects especially in those less than 3 years, puts them at risk of foreign body aspiration and ingestion. , However, major accidents such as motor vehicle collisions and accidents at places of work such as the nail gun injuries  and trauma following fights are commoner amongst adolescents and young adult, and various organs and body sites may be injured. In our common experience, cases of arrow penetrating chest wall injuries following fights had been recorded. Similarly, nail gun injuries penetrating the heart , and nail gun systemic embolization have been reported.  About 25% of traumatic deaths among Americans are cardiac-related injuries involving the heart and large vessels.  Adolescents and adults are mostly affected. However there is dearth of information on penetrating cardiac injuries involving Nigerian children. We therefore report a case of a penetrating cardiac injury in a 4-year-old Nigerian girl.
| Case Report|| |
A 4-year-old girl was suddenly seen with a nail protruding from the left side of her chest while playing with peers in the courtyard; the attention of the mother was drawn when she heard her cry. She was immediately taken to the hospital which took about 30 min. The child had been active with normal developmental milestone for age, no history of any family conflict and upon enquiries they could not ascertain the exact mechanism of injury since all the children involved were her peers. On examination, she was conscious, in pain, there was no significant active bleeding and she was not pale or cyanosed. The nail penetrated the chest through the fourth left intercostal space 2 cm from the left sternal margin inferior-laterally angulated [Figure 1] with about 3 cm protruding from the chest wall. The pulse rate was 120 beats/min, she had normal blood pressure of 100/70 mmHg and the jugular venous pressure was normal; the apex was at the fourth left intercostal space at the midclavicular line with a normal first and second heart sounds, no murmur. Other systems examinations were not remarkable. Based on the site and estimated length of the nail, it was assumed the nail was in the heart as shown by chest X-ray [Figure 2]. The nail was approached via an anteriolateral thoracotomy at the fourth left intercostal space; she had left-sided hemothorax but the lung was spared; there was also hemopericardium but no active bleeding was noticed afterward. The nail was extracted and sutures tied with no bleeding. Saline lavage of the pleural space was done and chest tube size 18 was inserted and the wound closed in layers. Intra-operation the nail penetrated into the right ventricle with a measured intracardiac length was 6 cm from the pericardium and a 3.5 inches nail was extracted. She was discharged a week later [Figure 3] after electrocardiogram and repeat echocardiogram confirmed normal cardiac structure and function [Figure 4].
|Figure 2: Chest X‑ray (anterior‑posterior view) showing the radio‑opaque nail penetrating the chest wall|
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| Discussion|| |
Nail in the heart in children is a rare event and had never been reported before among Nigerian children to the best of our knowledge. The severity of morbidity or risk of mortality depended on the extent of organ damage. In 532 cases of penetrating cardiac injuries; the right ventricle, right atrium, left ventricle, left atrium and aorta were affected in 35, 33, 25, 14, and 14%, respectively.  The right ventricle is mainly anterior and retrosternal, therefore it is more prone to penetrating and blunt injury. The right ventricle was involved in this case because the penetration was more anterior, but no other intracardiac damage was recorded despite the intracardiac length of 6 cm. This is because the nail's axis aligned with that of the right ventricle, therefore sparing the ventricular septum and valves.
Patients with penetrating cardiac injuries maybe stable as it was in this case, while others may present with unstable vital signs and in severe cases in cardiac tamponade. 
Furthermore the nail was not barbed bearing in mind our limitations in heart surgery; otherwise removal without incising the myocardium would not have been easy as is seen in arrow-related penetration injury. The fact that the nail was not tampered with before presentation prevented massive bleeding into the pericardial space which could have resulted in cardiac tamponade.
The role of imaging especially echocardiography in the management of this patient cannot be overemphasized; the inability to explore the heart intraoperatively to determine the extent of injury was solved by the postoperative echocardiogram. Transthoracic echocardiography can determine valvular and left ventricular functions and also detect the presence of pericardial effusion and cardiac tamponade. In recent series of patients with cardiac penetrating chest wounds and stable vital signs; two dimensional echocardiography was found to be 90% sensitive and 97% specific for the diagnosis of cardiac penetration; , though other modalities like magnetic resonance imaging, angiography are helpful diagnostic tools, but axial multidetector computer tomography (CT) scan better defines the extent and mechanism of cardiac and mediastinal injuries which will certainly determine the approach to management. Furthermore CT scan can also detect pneumothorax, pneumopericardium, pleural and pericardial effusions, pericardial or myocardial lacerations, and cardiac luxation.  It can also define wound tracks in penetrating trauma  and can show retained foreign bodies; but its nonavailability in our setting does not undermine the effort made in this case; however we can do better if these facilities are made available.
| Conclusion|| |
The case of a 4-year-old Nigerian girl with nail penetrating into the right ventricle which was successfully extracted and was fortunate to have survived despite our limitations is reported. This is an indication that our doctors can do more if the necessary facilities are made available.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]