Chapter 100. Fishhook Removal

Depending on practice location and season of the year, the presentation of a fishhook embedded in the subcutaneous tissue can be common. The patient or a well-meaning bystander will often have already attempted removal that was prevented by the hook's barb. The ensuing tissue trauma and patient anxiety can complicate the task for the Emergency Physician. Removal can be difficult as a fishhook is designed not to pull out of a fish's mouth. Several methods of removal have been described.1–9 The method chosen depends on the type and size of the hook, the depth of penetration, and the anatomical location of injury.

Most fishhooks become embedded in the skin and subcutaneous soft tissue. The anatomy of a fishhook is simple (Figure 100-1). The long, straight section is known as the shaft. The proximal end of the shaft has a closed circle, the eyelet, where the fishing wire attaches. The distal end of the shaft curves in a semicircle known as the belly of the fishhook. The belly tapers into a sharp point with a barb. The barb is usually located on the inner surface of the hook, pointing away from the tip. The barb, once pierced through the skin, becomes embedded within the tissue and prevents removal of the fishhook. Additional barbs may be located along the shaft of the fishhook.

Any embedded fishhook must be removed from the body. There is no reason a fishhook should not be removed by the Emergency Physician if no contraindication exists.

There are no absolute contraindications to fishhook removal. Occasionally, the procedure should be referred to a consultant. Globe perforation or laceration requires emergent consultation with an Ophthalmologist. Place the patient supine with a shield, not a patch, over the eye. Please see Chapter 161 for the complete details regarding eye patching and eye shields. Penetration of, or near, vital structures (e.g., the neck, groin, or major neurovascular structures) should be given consideration for the appropriate surgical consultation prior to removal of the fishhook.

• Povidone iodine or chlorhexidine solution
• Local anesthetic solution without epinephrine
• 3 mL syringe armed with a 25 gauge needle
• Wire cutter
• Needle driver
• Hemostat
• 18 gauge needle
• #11 scalpel blade on a handle
• String, fishing line, or a strong silk tie, at least 50 cm in length
• Tongue depressors
• Safety glasses/goggles or a face mask with an eye shield

Explain the risks and benefits of the procedure to the patient and/or their representative. Ask the patient to describe the type of fishhook embedded, especially in regards to the number and location of the barbs. Ask the patient to draw a picture of the fishhook or provide you with a similar one to examine. The number and location of the barbs will help in determining the appropriate removal technique. Obtain a signed consent form prior to beginning the procedure. Cleanse the skin of any dirt and debris. Apply povidone iodine or chlorhexidine solution to the skin surrounding the embedded fishhook and allow it to dry. The Emergency Physician should wear eye protection when removing a fishhook to prevent injuring themself. At minimum, wear safety glasses or goggles. If available, a face mask with an eye shield is preferred.

Pull‐Through Technique

This is the traditional method that is used for larger sized hooks embedded in the soft tissue with the barb near the skin surface. This is the preferred technique for fishhooks embedded in the ear, a joint, or in the nasal cartilages. Experienced fishermen often perform this technique in the field, as they would hate to lose prime fishing time to go to the Emergency Department.

Identify the barbed end of the fishhook, located under the skin surface. Inject 0.5 to 1.0 mL of local anesthetic solution into the subcutaneous tissue overlying the barbed end of the fishhook to raise a skin wheal (Figure 100-2A). Allow 3 to 4 minutes for the local anesthetic solution to take effect. Grasp the shaft of the fishhook with a needle driver (Figure 100-2B). Advance the fishhook until the barbed end protrudes through the anesthetized skin (Figure 100-2B). Securely clamp a hemostat over the barb. This will prevent it from becoming a projectile when cut and injuring someone. Cut the belly of the fishhook just proximal to the barbed end with a wire cutter (Figure 100-2C). Grasp the shaft of the fishhook with the needle driver and withdraw it along its direction of entry (Figure 100-2D).

Occasionally, fishhooks may have additional barbs on the shaft or the belly (Figure 100-3). Inject 0.5 to 1.0 mL of local anesthetic solution into the subcutaneous tissue overlying the barbed end of the fishhook (Figure 100-3A). Allow 3 to 4 minutes for the local anesthetic solution to take effect. Grasp the shaft of the fishhook with a needle driver (Figure 100-3B). Advance the fishhook until the barbed end protrudes through the anesthetized skin (Figure 100-3B). Continue to advance the fishhook until all the barbs on the belly and shaft are below the skin surface (Figure 100-3B). Securely clamp a hemostat over the proximal shaft of the fishhook (Figure 100-3C). Cut the shaft of the fishhook at the level of the skin with a wire cutter (Figure 100-3C). Grasp the fishhook just proximal to the barbed end with the needle driver and pull the remainder of the fishhook out of the tissues (Figure 100-3D).

Barb-Sheath Technique

This method is reserved for small fishhooks embedded near the skin surface. This technique should not be used for fishhooks in the ear, nose, or a joint cavity. Inject 0.5 to 1.0 mL of local anesthetic solution to form a wheal subcutaneously around the area where the fishhook enters the skin. Insert an 18 gauge needle along the entrance wound and aimed toward the barb (Figure 100-4A). The bevel of the needle should face the barb with the goal being to engage and cover the barb. Advance the needle and engage the barb in the core of the needle (Figure 100-4B). Gently twist and pull the hook back through the entrance wound while the needle covers the barb (Figure 100-4C).

An alternative method is to insert a #11 scalpel blade parallel to the shaft of the fishhook at the site it enters the skin. Advance the scalpel blade until it is adjacent to the barb. Withdraw the fishhook and scalpel through the tract. The barb will be resting against the scalpel blade and not get embedded in the subcutaneous tissues. This method is not recommended due to the blind insertion of a scalpel blade into the soft tissues and the potential for secondary injury.

String-Yank Technique

This method has been extensively described and is often performed by experienced fishermen in the field. It is rapid, effective, easy to perform, and relatively painless. This technique should not be used for fishhooks in the ear, nose, or a joint cavity. The Emergency Physician should take caution for themselves, the patient, and bystanders. The hook often forcibly flies out of the patient. Ensure the suspected path of the fishhook is clear. Eye protection is recommended with this technique for both the Emergency Physician and the patient.

Place the body part that the fishhook entered firmly on a flat surface. Local anesthetic solution can be infiltrated, at the Emergency Physicians discretion, into the area where the fishhook enters the skin. Wrap the midpoint of a long string around the belly of the fishhook at the site it enters the skin (Figure 100-5A). The string ends should be firmly wrapped around and secured to the index and middle fingers of the Emergency Physician's dominant hand. Use the gloved nondominant thumb or index finger to firmly depress the shaft of the fishhook against the skin, until slight resistance is met (Figure 100-5B). The shaft should be parallel to the skin and touching the skin. This will disengage the barb from the soft tissues. Quickly and firmly jerk the string (Figure 100-5C). This maneuver will release the fishhook from the subcutaneous tissues and pull it out through the entry wound.

Alternatively, the Emergency Physician may use two tongue depressors to provide secure traction to the string. Wrap each end of the string around one tongue depressor. Instruct an assistant to gently depress the fishhook shaft against the skin while the Emergency Physician jerks the string.6

The wound should be cleaned of any blood and a dry dressing applied. Administer tetanus prophylaxis if the immunization history is not up-to-date. A radiograph is indicated if there is any suspicion of a retained foreign body. Acetaminophen or nonsteroidal anti-inflammatory drugs will provide any required analgesia. Instruct the patient to clean the area with warm soapy water three times a day and to keep the wound covered until healed. Instruct the patient as to the signs of infection. They should return to the Emergency Department, or their physician, if signs of an infection develop. Routine follow-up is often not required unless the fishhook penetrated the ear, nose, or a joint.

Antibiotic prophylaxis remains controversial.1,2 The use of antibiotics is left to the discretion of the Emergency Physician and should include consideration for the anatomic site of injury, depth of penetration, evidence of gross contamination, and factors that may compromise the patient's immunity (e.g., diabetes mellitus, HIV infection, steroid use, or malignancy). If antibiotic prophylaxis is chosen, prescribe a broad spectrum antibiotic such as trimethoprim-sulfamethoxazole or doxycycline. These will provide good coverage against gram-negative organisms typically associated with water recreation injuries, as well as some coverage against MRSA and other community acquired infections.7 Adding ciprofloxacin for pseudomonas coverage may also be considered, as pseudomonas and its subtypes are commonly found in soil and freshwater.6

Complications include infection or damage to the surrounding tissue. Infection is often due to either the contaminated fishhook inoculating the tissues or the fishhook penetrating contaminated skin. Using proper removal techniques will minimize, but not eliminate, any damage to the soft tissues.

Use caution when extracting fishhooks to avoid secondary injury to bystanders, the patient, or the Emergency Physician. Protective eyewear should be worn with all three techniques of fishhook extraction. Ocular injury has been reported to occur during this procedure.2 Fishhooks have been surgically extracted from the hypopharynx and the intestine.8,9 A surgical face mask with a face shield is another mode of protection that we recommend. When using the pull-through technique, clamping a hemostat to the exposed portion of the fishhook that is to be cut off will prevent flying shrapnel.

Fishhook removal can be accomplished by one of several simple techniques. It can be performed in the Emergency Department, the office, or the field with minimal supplies. Almost painless removal is possible in most cases. This procedure is gratifying both for the patient and the Emergency Physician.