Department of Emergency Medicine | Saint John

When you catch more than fish – a Resident Clinical Pearl on Fish Hook Removal

Melanie Johnston

PGY2, FMEM Program, Dalhousie University

Reviewed & Copyedited by Dr. Mandy Peach

Introduction

Fishing is a common recreational activity in the Maritime provinces and fishhook injuries are common presentations among both recreational and commercial fishers, particularly during the warm weather months. Individuals may try to remove the fishhook themselves prior to presenting to the emergency department. While some may be successful, many will require evaluation and management in the emergency department for removal.

The majority of fishhook injuries are penetrating soft tissue injuries involving the hands, feet, or head, but can involve any body part.1 Most injuries involve superficial structures because of the forces applied to the fishing line that drive the barb parallel to the skin and keep it from penetrating deeper structures. There are four commonly used techniques to remove fishhooks, and the choice of technique will depend on the body part affected, depth of penetration, and the type of fishhook.2

Initial Evaluation

To determine the most appropriate technique for removal:

• Determine what type of fishhook was being used (shape, size, # of hooks, location and # of barbs)
• Perform a thorough neurovascular exam both proximal and distal to wound
• Assess penetration depth; if difficult to assess, radiographs should be utilized for further evaluation (rule out bone and joint involvement)
• Determine if tetanus immunization status is up to date

Figure 1: Types of fishhooks (A) Simple single barbed fishhook, (B) Multiple- barbed fishhook, (C)Treble fishhook.1

Complicated Fishhook Injuries

While the majority of fishhook cases are uncomplicated, those that require specialist referral and follow-up include: – fishhook injuries involving the eyeball or orbit – fishhook injuries with joint/tendon involvement – fishhook injuries involving vital structures (carotid, radial artery, testicle, urethra)

In these cases, specialist consultations are warranted prior to fishhook extraction.1-3

Figure 2: Fishhook injury involving eye.5

Preparation for Fishhook Removal

Wound preparation: remove any additional materials attached to the fishhook (fishing line, lures, weights) using scissors/wire cutters. Surrounding skin should then be cleansed (betadine, chlorhexidine, saline irrigation).1

Pain control: Local or regional anesthesia is sufficient for most cooperative patients. If the hook is embedded in fingers or toes consider a digital block. Young children may warrant procedural sedation if uncooperative.

Tetanus prophylaxis: Status should be verified and prophylaxis given when indicated.

Four Primary Techniques for Fishhook Removal

The four primary techniques described for the removal of fishhooks are:

• retrograde
• string-yank
• needle cover
• advance and cut.1-3

The retrograde and string-yank methods generally result in the least amount of tissue trauma.

The needle cover and advance and cut techniques are generally reserved for more difficult fishhook removals.

It may take multiple techniques and attempts before a fishhook can be successfully removed. The physician should take care not to be struck by the hook on removal and eye protection should be worn.

Figure 3: Fishhook structure.6

Retrograde “Back Out” technique:

Lowest success rate. Works well for barbless/superficial embedded hooks.1

Figure 4: Retrograde technique.1

• Apply downward pressure to the shank of the hook (helps to rotate the gook and disengage the barb)
• Back the hook out of the skin along the path of entry
• If any resistance/catching of the barb is experienced, should stop and consider other removal techniques

String-Yank Technique:

Modification of the retrograde technique. Considered to be least traumatic as it creates no new wounds.1 Generally works best on small-medium sized hooks. Cannot be performed on parts of the body that are not fixed (eg. earlobe).

Figure 5: String-Yank Technique

• Wrap a 3-0 silk culture around the midpoint of the bend in the fishhook with the free ends of the string held tightly (can achieve a better grip wrapping the free ends around a tongue depressor or around the providers fingers)
• Stabilize the involved skin area against a flat surface as the shank is depressed parallel against the underlying skin
• Apply a firm quick pull parallel to the shank while continuing to exert pressure on the fishhook
• Examine hook to ensure that the barb is intact and has been removed

Failure of this technique is most often due to non-forceful pull.

Needle Cover Technique:

Works well for removal of large hooks with single barbs that are superficially embedded and can be easily covered by a needle.3

Figure 6: Needle Cover Technique

• Advance an 18 gauge (or larger) needle along the entrance wound of the fishhook
• Direction of insertion of needle should be parallel to the shank, with the bevel pointing towards the inside of the curve of the fishhook (allows the needle to engage the barb)
• Advance the fishhook to disengage the barb, then pull and twist so that the point of the hook enters the lumen of the needle
• Back the fishhook out of the path of entry, moving the needle along with the fishhook

Advance and Cut Technique:

Almost always successful, irregardless of fishhook size. Disadvantage of this technique is additional trauma to surrounding tissue. This technique is most effective when the point of the fishhook is located near the surface of the skin.3

Figure 7: Advance and Cut technique

• Using a needle driver (or pliers), advance the fishhook, including the entire barb, through the skin
• Cut the advanced portion (including barb) free with pliers or other cutting tool
• Remove the remaining portion of the fishhook back out of the original entrance wound (should be no resistance)

Post Fishhook Removal Wound Care – Explore wound for possible foreign bodies (bait) – Generally wound is left open to heal by secondary intention – Rinse wound with normal saline irrigation post fishhook removal – Consider application of antibiotic ointment and simple dressing – Majority of individuals with superficial wounds do not require prophylactic antibiotics; consider in those who are immunosuppressed or who have poor wound healing (diabetics, peripheral vascular disease).

• The most common pathogens involved in fishhook wound infections are Staph aureus, and Strep pyogenes originating from the patients’ skin flora. As such oral antibiotic coverage could include five days of: Keflex, Penicillin, Amoxicillin, Clindamycin, Septra. – Antibiotics for any deep wound involving tendons, cartilage, or bone – Discuss monitoring for signs/symptoms of infection and return for reassessment if any complications – Patients who receive antibiotics should be scheduled follow up evaluation in 2-3 days to assess for signs of infection

Bottom Line: Fishhook injuries are common emergency department presentations among both recreational and commercial fisherman. The majority of these injuries are superficial, soft tissue injuries that can be managed with one of the four techniques described above.

The initial evaluation of these patients should include a thorough neurovascular exam and assessment to determine any features that would deem the injury complicated (joint/bone involvement, orbit/eyeball involvement, vascular injury) requiring specialist consultation or further investigations (Xray).

The choice of technique utilized will vary depending on type of fishhook, location of injury, depth, and practitioner comfort. Some injuries may require multiple attempts and techniques before the hook will be successfully removed.

Post fishhook removal, the wound should be thoroughly irrigated and left to heal by secondary intention. The majority can be managed with antibiotic creams and at-home monitoring for signs of infection, but those at risk of poor wound healing can be considered for prophylactic antibiotics.

References: 1. Gammons, M.; Jackson, E. Fishhook Removal. Am Fam Physician. 2001 Jun 1;63(11):2231-2237. Retrieved from https://www.aafp.org/afp/2001/0601/p2231.html.

1. Bothner, J. Fishhook removal techniques. Updated Mar 01, 2020. Retrieved from: https://www.uptodate.com/contents/fish-hook-removal-techniques?search=fishhook%20removal%20&source=search_result&selectedTitle=10~150&usage_type=default&display_rank=10#H13

2. Riveros, T., Kim, J., Dyer, S. Trick of the Trade: Fishhook Removal Techniques. 2018, Jan 8. Retrieved from: https://www.aliem.com/trick-fishhook-removal-techniques.

3. Cover photo: https://www.outdoorlife.com/photos/gallery/fishing/2012/04/survival-skills-how-remove-fish-hook-and-treat-injury/

4. Inchinogolo, F. Fish-hook injuries: a risk for fisherman. Head & Face Medicine Volume 6, Article number: 28 (2010)

5. Fish hook structure, retrieved from: https://en.wikipedia.org/wiki/Fish_hook