CASE

A 45-year-old male presents to the emergency department with a chief complaint of a fishhook injury. He was fishing on the beach this morning and caught a large fish. When he attempted to unhook the fish, he accidentally embedded the fishhook into his left hand. He attempted to remove the hook unsuccessfully prior to arrival. His tetanus status is up to date.

DIAGNOSIS

Embedded fishhook

DISCUSSION

Depending on practice location and time of year, fishhook injuries can be relatively common complaints in the emergency department. When examining the affected tissue, it is important to evaluate what type of fishhook was being used (shape, number of hooks, how many barbs, etc) [1]. There are multiple different techniques that can be employed for fishhook removal.

Methods For Fishhook Removal

Simple Retrograde Technique

Press the external portion of the hook toward the skin to disengage the barb. Slowly back the hook out of the skin. If the barb catches on skin fibers, other methods must be used.

String-Pull Technique

This technique is quick and generally does not require local anesthesia. Although effective, this technique cannot be used on hooks embedded in ears, the nose, or joint cavities. This technique is more suited for single hooks that are embedded into stable surfaces such as arms, the back, and the scalp region [4]. Wrap a piece of 0-nylon around the hook to secure it. Exert downward pressure on the eye of the fishhook to disengage the barb. While holding the nylon, forcefully pull 180 degrees from the site of insertion [2]. Proceed with caution as the fishhook will be propelled out rapidly and can cause additional injury. Both the practitioner and the patient should wear protective eyewear while performing this technique.

Needle Cover Technique

An 18-gauge needle is inserted though the skin alongside the shank of the hook and advanced over the barb. The entire hook-needle unit is then reversed out of the skin. This technique requires great dexterity and is the least successful overall [3].

Advance and Cut

Provide local anesthesia to the affected area. Advance the hook forward until the barb of the hook exits through the skin. Cut the barb off of the hook outside of the skin. Reverse the hook back out through the original entry point [3]. This method does cause additional trauma and is only warranted when the barb is already nearly exiting the skin.

Post-Removal Care

After successful removal of the fishhook, the wound should be explored for retained foreign bodies (bait). Tetanus toxoid should be administered if more than five years has elapsed since the last booster. Controlled studies do not exist that support the need for systemic antibiotics [7]. Prophylactic antibiotic therapy may also be considered for patients who are immunosuppressed or have poor wound healing (e.g., patients with diabetes mellitus or peripheral vascular disease), or for deeper wounds that involve tendon or bone [6]. Patients should be prompted to return for reevaluation if they develop signs of infection (redness, swelling, drainage of pus, or fevers).

TAKE-AWAYS

• Embedded fishhooks are relatively common complaints in the emergency department

• There are multiple methods that can be employed to remove a fishhook, including the simple retrograde, string and pull, advance and cut, and needle cover techniques.

• After removal, the wound should be explored for retained foreign bodies, and tetanus toxoid booster should be updated if applicable.

• Systemic antibiotics are not routinely recommended after fishhook removal, but could be considered for obviously contaminated wounds, deep wounds, or in patient populations that are immunosuppressed or are at risk for poor wound healing.

AUTHOR: Lindsey Brown, MD, is a current second year resident at Brown Emergency Medicine

FACULTY REVIEWER: Michelle Myles, MD, is an attending physician at Rhode Island Hospital and Miriam Hospital.

REFERENCES

[1] Riveros, Toni. “Trick of the Trade: Fishhook Removal Techniques.” ALiEM, 15 May 2021, www.aliem.com/trick-fishhook-removal-techniques/. Accessed 20 Feb. 2024. 

[2] Izadpanah, Kayvon, and Amita Sudhir. “Angling for Success: Techniques for Fishhook Removal in the Ed.” EMRA, 9 Aug. 2017, www.emra.org/emresident/article/angling-for-success-techniques-for-fishhook-removal-in-the-ed#:~:text=An%2018%2D%20or%2020%2Dgauge,can%20then%20be%20simultaneously%20removed.&text=The%20string%20yank%20technique%20is%20quick%20and%20anesthetic%2Dfree. Accessed 20 Feb. 2024. 

[3] Gottlieb, Michael. “Fishhook Injury.” WikEM, 29 June 2021, wikem.org/wiki/Fishhook_injury. Accessed 20 Feb. 2024. 

[4] Trinh, William, et al. “Emergency Medicine Techniques, Equipment List for Removing Fishhooks Lodged in Patients - Page 4 of 4.” ACEP Now, 15 June 2016, www.acepnow.com/article/emergency-medicine-techniques-equipment-list-removing-fishhooks-lodged-patients/4/?singlepage=1. Accessed 20 Feb. 2024. 

[5] “Figure: Fish Hook Removal: Needle Cover Method.” Merck Manuals Professional Edition, www.merckmanuals.com/professional/multimedia/figure/fish-hook-removal-needle-cover-method. Accessed 20 Feb. 2024. 

[6] Gammons, Matthew, and Edward Jackson. “Fishhook Removal.” American Family Physician, American Academy of Family Physicians, 1 June 2001, www.aafp.org/pubs/afp/issues/2001/0601/p2231.html. Accessed 20 Feb. 2024. 

[7] Doser C, Cooper WL, Ediger WM, Magen NA, Mildbrand CS, Schulte CD. Fishhook injuries: a prospective evaluation. Am J Emerg Med. 1991;9:413-5.