Introduction
Fishing is a popular outdoor activity worldwide. In the United States alone, it is estimated that there are more than 34 million anglers. Fishhook injuries are common in both commercial and recreational fishing. Fortunately, most fishhook injuries result in only minor soft tissue trauma. Although patients often have hooks removed in the field, these injuries may be encountered in the office or urgent care setting.
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The majority of patients with fishhook injuries present with an embedded hook. The most common locations for these injuries are the hands, face, head, and upper extremities. The special techniques that are required for removal of embedded fishhooks are outlined in this chapter. Although severe injuries are uncommon, ocular involvement could result in a penetrating globe injury and requires emergent ophthalmologic consultation. Hooks with deep tissue penetration in areas that may involve tendons, vessels, nerves, or bone require a thorough evaluation prior to removal. Rarely radiographs or ultrasound may be required to determine the depth of hook penetration and relation to important anatomical structures. Neurovascular status should be assessed in all patients with fishhook injuries.
The optimal fishhook removal technique depends on the type of hook that is embedded. There are many different styles and sizes of fishhooks. However, the most common types are single-barbed straight-shank hooks (A), multibarbed straight-shank hooks (B), and treble hooks (C). Single-barbed straight-shank hooks may be removed using several techniques including the retrograde technique, the string technique, or the needle cover technique. The retrograde technique is the easiest to perform because it does not require special equipment or local anesthesia, but is the least likely to succeed. The string technique can also be used without anesthesia on single-barbed straight-shank hooks. The other hook removal techniques require local anesthesia. The advance and cut techniques are best used for multibarbed and treble hooks.
Equipment
- Needle-nosed pliers or needle driver to grasp hook
- Wire cutter or heavy pliers with wire-cutting shear
Indications
- Superficially embedded fishhook injuries
Contraindications
- Ocular involvement
- Deep penetration into tendon, bone, major blood vessel, or nerve
The string technique should be avoided on mobile structures (earlobes).
The Procedure
Retrograde Technique
Step 1
Downward pressure is applied to the shaft of the hook to disengage the barb. Downward pressure is maintained and the hook is backed out of the skin along the path of entry.
- PITFALL: If resistance is encountered while removing the hook, the procedure should be discontinued and a different technique should be attempted.
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String Technique
Step 1
A string is tied to the midpoint of the hook bend and grasped 3 to 4 inches from the hook. Downward pressure is applied to the shaft of the hook to disengage the barb. A firm quick tug on the sting is preformed at a 45-degree angle to the skin while downward pressure on the hook shank is maintained.
- PITFALL: Do not use the string technique on mobile tissue such as earlobes.
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Needle Cover Technique
Step 1
Local anesthesia is administered. An 18-gauge needle is advanced along the fishhook until the needle covers the barb of the hook. The hook and needle are backed out of the wound simultaneously.
- PITFALL: Multiple needle stick attempts will increase injury to the surrounding soft tissue and may cause bleeding or hematoma formation.
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Advance and Cut Technique
Step 1
Local anesthesia is administered. Large needle drivers or pliers are used to advance the barb of the hook through the skin. For multibarbed single-shaft hooks, the hook shaft is cut with wire cutters and the hook is pulled forward out of the wound. For single-barbed or treble hooks, the point of the hook including the barb is cut with wire cutters and the hook is backed out of the wound.
- PITFALL: Local anesthesia must be placed where the hook will exit the skin otherwise the procedure will be poorly tolerated.
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Complications
- Bleeding
- Hematoma
- Infection
- Retained foreign body
- Injury to surrounding structure (tendon, bone, blood vessel, or nerve)
Pediatric Considerations
Although the removal techniques are unchanged, pediatric patients are more likely to be uncooperative because of anxiety. As with any pediatric procedure, it is best to approach the child calmly at his or her level. The child may remain in the parent or caretaker 's lap facing toward the clinician. For children younger than 5 years of age, it may be necessary to use a papoose board or conscious sedation.
Postprocedure Instructions
After fishhook removal, wounds should be examined carefully for retained foreign bodies. Puncture wounds should generally be left open and covered with a simple dressing. Prophylactic antibiotics are unnecessary for most patients but may be considered in immunocompromised patients such as diabetics. Neurovascular status should be reassessed and tetanus immunization should be confirmed or updated.
Coding Information and Supply Sources
View Large CPT Code Description 2008 Average 50th Percentile Fee GLobal Period 10120 Incision and removal of foreign body, simple subcutaneous $165.00 10 10121 Incision and removal of foreign body, complex subcutaneous $417.00 10 23330 Foreign body removal shoulder subcutaneous $355.00 10 24200 Foreign body removal upper arm or elbow subcutaneous $355.00 10 CPT is a registered trademark of the American Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008 MMH-SI 's copyrighted Physicians ' Fees and Coding Guide.
Needle-nosed pliers, wire cutters, and heavy pliers with wire shears are available at any hardware store. A suggested anesthesia tray that can be used for this procedure is listed in Appendix F.
Bibliography
1
Doser C, Cooper WL, Edinger WM
Fishhook injuries: a prospective evaluation.
Am J Emerg Med.
1991;9:413 " 415. [View Abstract]
2
Eldad S, Amiram S. Embedded fishhook removal.
Am J Emerg Med.
2000;18:736 " 737. [View Abstract]
3
Gammons M, Jackson E. Fishhook removal.
Am Fam Physician.
2001;63:2231 " 2236. [View Abstract]
4
Terrill P. Fishhook removal.
Am Fam Physician.
1993;47:1372. [View Abstract]
5
2008 MAG Mutual Healthcare Solutions, Inc. 's
Physicians ' Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.
2007.