Sean, a 14-year-old boy, was out fishing with friends. While tidying away his gear, a used barbed fishhook became lodged in his second finger on his right (dominant) hand. Sean and his friends attempted to remove the hook but were unsuccessful. Sean feels otherwise well, has no long-term medical problems and is unsure when his last vaccinations were.
Is this a common problem?
Depending on where your Emergency Department is situated, a child with a fisk hook lodged somewhere can be an exceedingly rare or pretty common presentation. Most hooks will be embedded superficially in fingers or feet and be easily removed by an easy-to-master technique. However, some hooks can become lodged in eyes/ eyelids or have penetrated deeper. These may warrant a surgical referral. Let’s have a look at how we can evaluate which fishhooks can be removed in the ED and which ones we might be more cautious about.
What type of hook are we dealing with?
There are many different types of hooks. They vary both in size and the number of hooks or barbs present.
The most important thing for us to know as clinicians is whether the hook is barbed or not.
The most common type of hook has an eyelet at one end, a straight shank, and a curved belly that ends in a barbed point on the inner curve that points away from the hook’s tip as shown above.
Some fishhooks may be multi-hooked or have a lure (an artificial fishing bait) attached. These will need to be clipped from the main shank prior to removal. Some hooks will have multiple barbs along the shank. These hooks cause greater tissue damage.
What should we be looking out for?
When evaluating a lodged fishhook and its suitability for removal in the Emergency Department, consider the following:-
Important aspects in the history:
- Where the incident occurred i.e freshwater vs salt water?
- Whether or not the hook has been used?
- Vaccination status as they will require a tetanus booster if not up to date.
- History of immunocompromise and bleeding disorders.
Your examination should include:
- Site and depth of penetration. Most hooks will lodge superficially in fingers or hands, and less frequently in feet, the face or the head. These can be safely removed in the ED. Subspecialty consultation should be obtained for fish hooks lodged in the eye or eyelid, vascular structures, the genital area or if there is clinical evidence of neurovascular compromise. Careful assessment of the depth of penetration and integrity of surrounding structures and joints is important.
- Type of fishhook. See techniques below.
- Wound. Assess for active bleeding or evidence of gross contamination that may need management in theatre.
How are we going to remove the hook?
First off, good analgesia to manage the pain is paramount. Generally, local infiltrative anaesthesia is highly effective in older, cooperative patients. Younger children may require procedural sedation to facilitate this.
Next, think about the child’s tetanus status and give prophylaxis as indicated.
And thirdly, think carefully about your removal techniques. Five techniques of fishhook removal are described. Your choice of technique depends on:
- Type of hook
- Depth of entrapped point
- Body part involved
Regardless of the method used, all wounds should be cleaned and prepped prior to removal. If the hook is multi-hooked or if there is a lure attached, clip off the end before you attempt removal to minimise tissue damage. The objective of each technique is to disengage the barb with as little tissue trauma as possible. Let’s take a look at the five techniques.
The back-out technique
The back-out technique can only be used with a barbless fishhook. Simply grasp the shank of the hook and back the hook out of the wound.
The push-through technique
This technique can be used for superficially embedded barbed hooks where the point of the hook is close to the skin. To avoid injury from the barb, you should always wear protective equipment.
The string method
The string technique can be used for single barbed hooks that are embedded in a body part that can be firmly secured so that it does not move during the procedure. It fails if the force isn’t sudden enough so don’t be afraid to give the string a good pull.
The needle technique
This technique works well with larger hooks that are superficially embedded. A needle is used to cover the barb therefore the hook can be backed out the entry wound. It can be difficult and is only to be used once other techniques have failed.
Cut it out
When all other techniques have failed, you may consider cutting out the hook. Under adequate anaesthesia, an incision is made along the body of the hook and the hook is removed.
What about once the hook has been removed?
The name of the game here is to minimise the risk of infection. Firstly, thoroughly irrigate the wound with normal saline.
Should I give empiric antibiotics?
No clinical trial to date has addressed the need for empirical antibiotics in fishhook wounds. In general, empirical antibiotics are prescribed.
If the hook was not contaminated, empiric antibiotics for skin flora is recommended. Treat as if there might be uncomplicated cellulitis and follow local guidelines.
If the hook was contaminated, consider other pathogens including Aeromonas, Edwardsiella tarda, Vibrio vulnificus and Mycobacterium marimun. Use an oral first-generation cephalosporin or, in patients with acephalosporin allergy, oral clindamycin, plus an oral fluoroquinolone such as levofloxacin. If there is seawater exposure, add doxycycline to cover for Vibrio (although avoid in children under 8 as it causes teeth discolouration and enamel hypoplasia). If there was soil contamination or exposure to sewage-contaminated water, add metronidazole to cover for anaerobes, unless you are already using clindamycin.
Sean’s hooked was embedded superficially in the finger pulp, with no evidence of damage to deeper structures. It was removed with ease in the Emergency Department using the push-through technique. His wound was thoroughly cleaned and he was discharged with a prescription for prophylactic antibiotics. He was given a tetanus booster and educated on the signs and symptoms of wound infection.
Aiello LP, Iwamoto M, Guyer DR. Penetrating ocular fish-hook injuries. Surgical management and long-term visual outcome. Ophthalmology. 1992;99(6):862. 1630774
Malitz DI. Fish-hook injuries. Ophthalmology. 1993;100(1):3. 8433823
Su, E. Removal of a barbed fishhook. In: Illustrated Textbook of Pediatric Emergency and Critical Care Procedures, Diekema, RA, Fiser, DH, Selbst, SM (Eds), Mosby, St. Louis 1997. p.727