Fish hook removal techniques

INTRODUCTION — Fish hooks may lodge in any body part, but the fingers and feet are most commonly involved. Most embedded fish hooks can be removed in the emergency department. The choice of removal technique depends on the depth of penetration, body part affected, and type of fish hook. This topic will discuss fish hook removal techniques.

INDICATIONS — Any clinician may remove fish hooks that are superficially embedded in the skin. Fish hooks embedded in the eye, eyelid, or in vital structures should be removed by the appropriate surgical specialist.

CONTRAINDICATIONS — There are no absolute contraindications to fish hook removal. Subspecialty consultation should be obtained for fish hooks lodged in the eye, eyelid, or in vital structures (eg, carotid artery, radial artery, peritoneum, testicle, urethra) or when a hook is embedded very near to these structures [1-3].

Initial emergency management of penetrating injuries to the eye is found in the table (table 1). (See "Open globe injuries: Emergency evaluation and initial management".)

TYPES OF FISH HOOKS — Most fish hooks lodge in the dermis or subcutaneous layers of the skin. 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 (figure 1). Because the barb is set into the tissue, the fish hook cannot be pulled out by the shank without causing tissue damage unless the barb is somehow disengaged from the tissue.

Fish hooks without barbs are easy to back out with minimal tissue damage. (See 'Back-out technique' below.)

Some commercial fish hooks have prominences along the shank and may have multiple hooks with barbs. The approach to removal of multi-hooked fish hooks involves the same techniques as described for single barbed fish hooks. However, the multiple hooks should be clipped so that they are no longer connected to the main shank, yet retain adequate individual shank length to permit individual removal of each hook. Removal of multi-hooked fish hooks tends to be associated with greater tissue trauma.

PREPARATION — The preparation for fish hook removal involves assessment of the type of fish hook that is embedded, the circumstances of the injury, the depth of the fish hook barb, and the potential for injury to the eye or other vital structures. (See 'Contraindications' above.)

Key interventions include:

●Wound preparation – While stabilizing the lodged hook with a hemostat, fishing line, lures, weights, and any other material attached to the embedded hook should be removed using scissors or wire cutters or by disassembling them. The surrounding skin should then be cleansed with betadine.

●Pain control – When indicated, local or regional infiltrative anesthesia suffices for most cooperative patients. A digital block is often necessary for hooks deeply seated in the fingers or toes. Occasionally, young children may warrant procedural sedation. (See "Digital nerve block" and "Subcutaneous infiltration of local anesthetics" and "Procedural sedation in children: Approach".)

●Tetanus prophylaxis – Tetanus status should be verified and prophylaxis given when indicated (table 2). (See "Tetanus".)

PROCEDURE — Several techniques for removing fish hooks have been described [3-8]. The choice of technique varies depending upon the type of hook, the depth of the entrapped point, and the body part involved. All share the same objective; to disengage the barb of the hook so that atraumatic removal is possible.

Techniques — The four most commonly used techniques include the back-out method, the push-through method, the string technique, and the needle technique [5]. The cut it out method increases the risk of tissue damage but can be used if other methods fail.

Back-out technique — The back-out method is the easiest method of removal. However, it can only be used with barbless hooks.

●After the skin and hook are prepped with betadine solution, the shank of the hook is grasped with a hemostat and backed out of the wound.

●Infiltration of local anesthesia may or may not be necessary depending upon the patient's ability to cooperate [3]. (See "Subcutaneous infiltration of local anesthetics".)

Push-through technique — The push-through technique causes minimal additional soft tissue trauma and is most effective when the point of the hook is near the surface of the skin (figure 2) [6].

●To avoid inadvertent injury from the barb, the patient, clinician, and other care providers in the room should wear protective eye gear.

●The skin overlying the point of the hook should be anesthetized, when indicated, either by local infiltration with 1 percent lidocaine or by digital block.

●After anesthesia is obtained, the shank of the hook is grasped with a hemostat or gloved finger and thumb, and the hook is advanced into the wound until the barb reemerges from the skin.

●The barb is cut off with a wire cutter and the remainder of the hook is then backed out of the wound.

●The resultant exit wound is small and does not require suturing or definitive repair [3].

String technique — The string technique can be used in the field for single barbed hooks and has been employed by fishermen for many years with excellent success. This technique can only be used when the fish hook is embedded in a body part that can be firmly secured so that it does not move during the procedure. Because the technique is rapid and causes little additional trauma, it can often be performed without local anesthesia [6].

●To avoid inadvertent injury, the patient, clinician, and other care providers in the room should wear protective eye gear.

●A piece of string or large (3-0) silk suture is looped around the belly of the fish hook (figure 3); the ends of the string should be wrapped securely around the clinician's index finger.

●The hook's belly should be directly in front of the clinician with the shank pointing in the opposite direction.

●The shank and eye of the fish hook should be firmly depressed with the clinician's other hand; this force will help to disengage the barb from the surrounding tissue.

●The string is pulled slowly until it is taut in the plane of the long axis of the hook; when it is taut, it is jerked quickly and firmly in the same direction, which pulls the hook out of the skin (figure 3).

●The freed hook should be examined to ensure that the barb of the hook is present and not broken off within the wound.

●Failure of this technique is most often due to a less than sudden and forceful jerking on the string [4,6,9,10].

Needle technique — The needle technique uses a needle to cover the barb, permitting the hook to be backed out of the entry wound. This technique is most effective when the hook is superficially embedded and works best with larger hooks. Although presented here, the needle technique may be difficult to perform successfully and may be best reserved for patients in whom the string or push-through technique has failed. (See 'Push-through technique' above and 'String technique' above.)

●The areas alongside the hook and at the entrance wound should be anesthetized, either by local infiltration with 1 percent lidocaine or by digital block. (See "Digital nerve block".)

●An 18- or 20-gauge needle is inserted through the wound along the shaft of the hook. The needle is advanced along the hook's belly, with the bevel of the needle facing the inside of the curve of the hook, until the needle opening slides over the barb.

●Once the barb is engaged, the needle and the hook are held firmly together and backed out of the wound as a unit (figure 4) [3,4,9].

Cut-it-out technique — Cutting out the hook is the last resort when other methods fail (figure 5) [5]:

●The skin is anesthetized at the entrance site.

●An incision is made with a scalpel along the body of the hook to the barb; for deeply embedded hooks, a hemostat is used to bluntly dissect to the barb once the skin incision is made.

●The hook is removed along the path of the incision.

POSTPROCEDURAL CARE — Complications, including infection, after fish hook removal are rare. The wound should be thoroughly irrigated with normal saline and covered with antibiotic ointment after the procedure is completed [11].

Empiric antibiotic therapy — No trials have addressed antibiotic therapy for fish hook injuries. Although most superficial fish hook wounds heal well without sequelae, we suggest that the occasional patient who has a fish hook that is deeply embedded in an infection-prone area (eg, fingertip, ear cartilage) receive empiric antibiotics:

●Fish hook wound infections are commonly caused by Staphylococcus aureus and Streptococcus pyogenes originating from the patient's skin flora that is introduced into the wound during the injury. Empiric antibiotic therapy for these organisms is the same as for the treatment of uncomplicated cellulitis. (See "Skin and soft tissue infections in children >28 days: Evaluation and management", section on 'Cellulitis' and "Acute cellulitis and erysipelas in adults: Treatment", section on 'Selecting an antibiotic regimen'.)

●If the hook was contaminated (eg, exposed to river, lake, pond, or sea water), then empiric antibiotic coverage may be warranted for other bacterial pathogens, including Aeromonas, Edwardsiella tarda, Erysipelothrix rhusiopathiae, Vibrio vulnificus, and Mycobacterium marinum. (See "Soft tissue infections following water exposure", section on 'Empiric therapy'.)

Follow-up — Patients with uncomplicated superficial fish hook injuries who do not receive empiric antibiotic therapy should be told to soak the wound in warm water two to three times per day until healing is established and advised to return if any signs of infection appear.

Patients with deeply embedded or contaminated fish hooks who receive empiric antibiotic therapy should be scheduled for a follow-up evaluation in two to three days to assess for signs of infection.

SUMMARY AND RECOMMENDATIONS

●Indications – Any clinician may remove fish hooks that are superficially embedded in the skin. Fish hooks embedded in the eye, eyelid, or in vital structures should be removed by the appropriate surgical specialist. (See 'Indications' above and 'Contraindications' above.)

●Types of fish hooks – 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 (figure 1). Because the barb is set into the tissue, the fish hook cannot be pulled out by the shank unless the barb is somehow disengaged from the tissue. (See 'Types of fish hooks' above.)

●Preparation – Prior to removal, the clinician should assess the circumstances of the injury, the depth of the fish hook barb, the type of barb, and the potential for injury to the eye or other vital structures. Key interventions include removal of fishing line, lures, weights, and any other material attached to the embedded hook, pain control, and provision of tetanus prophylaxis, as needed (table 2). (See 'Preparation' above and "Tetanus".)

●Techniques – Several techniques for removing fish hooks have been described. The choice of technique varies depending upon the type of hook, the depth of the entrapped point, and the body part involved. All share the same objective: to disengage the barb of the hook so that atraumatic removal is possible. (See 'Techniques' above.)

•The back-out technique is appropriate for barbless fish hooks. (See 'Back-out technique' above.)

•The push-through technique is most effective when the point is near the skin surface (figure 2). (See 'Push-through technique' above.)

•The string technique can be used in the field for single barbed hooks with excellent success. This technique can only be used when the fish hook is embedded in a body part that can be firmly secured so that it does not move during the procedure (figure 3). (See 'String technique' above.)

•The needle technique may be difficult to perform successfully and may be best reserved for patients in whom the string or push-through technique has failed (figure 4). (See 'Needle technique' above.)

•Cutting out the hook is the last resort when other methods fail (figure 5). (See 'Cut-it-out technique' above.)

●Empiric antibiotics – Most superficial fish hook wounds heal well without sequelae. For patients with fish hooks that are deeply embedded in an infection-prone area (eg, fingertip, ear cartilage), we suggest empiric antibiotic therapy with the regimen determined by the degree of wound contamination (Grade 2C). (See 'Empiric antibiotic therapy' above.)