Ricochet Nail Gun Penetration of Zone II With a Deep Cervical Trajectory: A Case Report.

Nail gun injuries to the neck are rare but potentially serious due to the concentration of vascular and aerodigestive structures within this region. Although considered low-velocity devices, ricochet mechanisms can create unpredictable trajectories, allowing nails to penetrate more deeply than expected. We report the case of a 49-year-old construction worker who sustained a zone II neck injury after a nail ricocheted off a hard surface and struck the left side of his neck. He arrived hemodynamically stable with only localized swelling and no airway or neurological symptoms. A CT angiography identified a curved metallic nail extending toward the C6-C7 level, closely abutting the left vertebral artery with a subtle non-obstructive intimal irregularity. Given the depth of penetration and proximity to major vessels, the patient underwent a selective neck exploration through an anterior sternocleidomastoid approach, allowing for the safe identification and removal of the nail under direct vision. Postoperative imaging confirmed preserved vertebral artery flow, and the patient recovered without complications. This case highlights how seemingly minor external findings may conceal a deep cervical trajectory, particularly when the mechanism involves ricochet. It reinforces the value of CT angiography in defining injury extent and supporting selective exploration in zone II penetrating trauma.