[Matt]

Part 2

Retrograde Technique
Retrograde technique is the simplest of the removal techniques but has the lowest success rate. It works well for barbless and superficially embedded hooks. Downward pressure is applied to the shank of the hook. This maneuver helps rotate the hook deeper and disengage the barb, if present, from the tissue. The hook can then be backed out of the skin along the path of entry (Figure 2). Any resistance or catching of the barb during the procedure should alert the physician to stop and consider other removal methods.
String-Yank Technique
The string-yank technique is a highly effective modification of the retrograde technique and is also referred to as the "stream" technique. It is commonly performed in the field and is believed to be the least traumatic because it creates no new wounds and rarely requires anesthesia.8 It may be used to remove any size fishhook but generally works best when removing fishhooks of small and medium size. This technique also works well for deeply embedded fishhooks, but cannot be performed on parts of the body that are not fixed (e.g., earlobe).9 Physicians should be familiar with the concepts of this method because improper technique could cause further tissue damage.

FIGURE 3. String-yank method. (A) Wrap a string around the midpoint of the bend in the fishhook. (B) Depress the shank of the fishhook against the skin. (C) Firmly and quickly pull on the string while continuing to apply pressure to the shank.
FIGURE 4. Needle cover method. (A) Advance an 18-gauge or larger-gauge needle along the fishhook until the needle opening covers the point. (B) The fishhook and needle are then removed at the same time. A string, such as fishing line, umbilical tape or silk suture, should be wrapped around the midpoint of the bend in the fishhook with the free ends of the string held tightly (Figure 3). A better grip on the string can be achieved by wrapping the ends around a tongue depressor.1 The involved skin area should be well stabilized against a flat surface as the shank of the fishhook is depressed against the skin. Continue to depress the eye and/or distal portion of the shank of the hook, taking care to keep the shank parallel to the underlying skin. A firm, quick jerk is then applied parallel to the shank while continuing to exert pressure on the eye of the fishhook. The fishhook may come out with significant velocity so the physician and bystanders should remain out of the line of flight. A commercial fishhook removal device, based on this technique, is available. (Minto Research and Development Inc., Redding, Calif.)10
The physician should always use protective eye wear when removing embedded fishhooks, especially when using the string-yank method.
Needle Cover Technique
The needle cover technique requires dexterity on the part of the physician. It works well for the removal of large hooks with single barbs but is most effective when the point of the fishhook is superficially embedded and can be easily covered by the needle. After skin preparation and administration of local anesthesia, an 18-gauge or larger needle is advanced along the entrance wound of the fishhook (Figure 4). The direction of insertion should be parallel to the shank. The bevel should point toward the inside of the curve of the fishhook, enabling the needle opening to engage the barb. It is important to have the bevel pointed in the correct direction so that the longer edge of the needle matches the angle of the fishhook point. The physician should advance the fishhook to disengage the barb, then pull and twist it so that the point enters the lumen of the needle. The physician can then back out the fishhook (the same way as in the retrograde technique), taking care to move the needle along the track with the fishhook.
A modification of this technique involves sliding a no. 11 scalpel blade along the wound to the point of the fishhook. The fishhook may then be backed out because the incision allows room for the point. This modification may also be used in combination with the needle cover technique for more difficult fishhook injuries.

FIGURE 5. Advance and cut method: single-barbed fishhook. (A) The fishhook is advanced through the skin. (B) The barb is then cut off and (C) the remaining hook is backed out through the entry wound.
FIGURE 6. Advance and cut method: multiple-barbed fishhook. (A) The fishhook is advanced through the skin. (B) The eye of the fishhook is then cut off and (C) the remaining portion of the fishhook is pulled through the exit wound created by advancing the point. Advance and Cut Technique
One advantage of this traditional method of fishhook removal is that it is almost always successful, even when removing larger fishhooks; however, additional trauma to the surrounding tissue is a disadvantage. The advance and cut technique is most effective when the point of the fishhook is located near the surface of the skin.9 It involves two methods of removal: one for single-point fishhooks (Figure 5) and one for multiple-barbed fishhooks (Figure 6). Infiltration with a local anesthetic is performed over the area where the fishhook has penetrated the skin. Using pliers or needle drivers, the point of the fishhook (including the entire barb) is advanced through the skin. The point is then cut free with the pliers or another cutting tool, allowing the rest of the fishhook to be backed out with little resistance.
For multiple-barbed fishhooks, the area should be anesthetized and the fishhook advanced. Instead of removing the point, the eye of the fishhook is removed. The physician can then continue to pull the fishhook in the same direction as the point was advanced.
Although it may produce additional tissue trauma, the major advantage of the advance and cut technique when removing an embedded fishhook is that it is almost always successful.
Post-Removal Wound Care
After removal of the fishhook, the wound should be explored for possible foreign bodies (e.g., bait). It is usually sufficient to leave the wound open, then apply an antibiotic ointment and a simple dressing. Tetanus toxoid should be administered to persons for whom more than five years has elapsed since their last tetanus booster. Well-conducted, controlled studies do not exist that support the need for systemic antibiotics in these cases; they are generally not indicated.7 Prophylactic antibiotic therapy may be considered for persons who are immunosuppressed or have poor wound healing (e.g., patients withdiabetes mellitus or peripheral vascular disease). Prophylactic antibiotic therapy may also be considered for deeper wounds that involve the tendons, cartilage or bone. Follow-up care should be performed to ensure adequate healing and the absence of infection.
MATTHEW GAMMONS, M.D., and EDWARD JACKSON, M.D. Michigan State University College of Human Medicine, East Lansing, MichiganREFERENCES

1. Lantsberg L, Blintsovsky E, Hoda J. How to extract an indwelling fishhook. Am Fam Physician 1992; 45:2589-90.
2. Aiello LP, Iwamoto M, Taylor HR. Perforating ocular fishhook injury. Arch Opthalmol 1992;110:1316-7.
3. Swanson JL, Augustine JA. Penetrating intracranial trauma from a fishhook. Ann Emerg Med 1992;21: 568-71.
4. White MF, Owens SD, Dooley CD, Kimble JA, Witherspoon CD. Fishing related eye injuries: a report of 27 cases. Invest Opthalmol Vis Sci 1990; 31:21.
5. Deramo VA, Maus M, Cohen E, Jeffers J. Removal of a fishhook in the eyelid and cornea using a vertical eyelid-splitting technique. Arch Ophthalmol 1999;117:541-2.
6. Morris JA, Swiontkowski MF, Merrmann HJ. Wilderness trauma emergencies. In: Auerbach PS, ed. Wilderness medicine: management of wilderness and environmental emergencies. 3d ed. St. Louis: Mosby, 1995:342-62.
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.
8. Haynes JH. Fishhook removal. In: Pfenninger JL, Fowler GC, eds. Procedures for primary care physicians. St. Louis: Mosby,1994:128-32.
9. Diekema DS, Quan L. Fishhook removal. In: Henretig FM, King C, eds. Textbook of pediatric emergency procedures. Baltimore: Williams & Wilkins, 1997:1223-7.
10. Rudnitsky GS, Barnett RC. Soft tissue foreign body removal. In: Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine. 3d ed. Philadelphia: Saunders, 1998:623-4.

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