POTD: Fishhook Injury

Hi everyone,

Caroline and I have the great privilege of serving as your admin residents for this upcoming block. Throughout the next four weeks, if there are any topics floating in your head that you would like us to dive further into, send it our way!

For today's POTD, I wanted to explore the unfortunate case of a fishhook injury, with a particular focus on fishhook removal techniques if it ever maneuvers its way into your ED. Over the weekend, the south side team successfully removed a fishhook lodged in a patient's pinky finger, and, by the leadership of Dr. Sanjeevan and the grip strength of Dr. Weber, the patient was able to ambulate out of the ED with all digits intact and ready for another day of fishing in Red Hook.

Fishhook Anatomy

A fishhook is composed of the eyelet, shank, belly, barb, and tip. Most fishhooks are J hooks, with one shank and one barb, but occasionally you might see a treble hook, which is essentially multiple J hooks together all sharing a shank. The real troublemaker for fishhook injuries is the barb. Fear the barb. The sharp, reversed nature of the barb makes it so that a simple retrograde removal would be traumatic both to the surrounding tissue and the patient.

Preparation

1) Assess path of fishhook: Your removal technique will in part depend on the depth and location of the needle. Is the distal tip already near the surface? Is it going to hit any important structures on its way in or out? You may need further imaging to better clarify the track it took. If it involves the eye, consult ophtho. If it involves bone or tendon, consult ortho.

2) Local anesthetic/nerve block: Digital blocks work great for these when applicable.

3) Wound cleaning: Chlorhexidine or betadine like wild.

Techniques

1) Advance and Cut Technique: need hemostat, wire cutters/raptors, gauze, eye protection

a. Anesthetize.

b. Advance the fishhook further into the patient until the tip and the barb have both exited the skin.

c. Cut the barb off the fishhook with wire cutters or raptors. If using raptors, you can use the ring cutter function (shown below). Make sure you keep gauze over the barb and have eye protection on before you cut so as to avoid the cut barb from flying off and causing further injuries.

d. Reverse the hook back out of the skin.

2) String Technique: need string or strong suture, eye protection

a. Wrap a string or strong suture around the fishhook.

b. Push down on the shank to dislodge the barb as much as possible.

c. Pull on the string and jerk quickly. Watch out for the fishhook to come flying out of the skin.

3) Needle Technique: need 18 gauge needle

a. Anesthetize.

b. Advance an 18 gauge needle along the fishhook toward the tip and over the barb.

c. Reverse out both the needle and fishhook together as a unit.

4) Scalpel Technique: need scalpel, hemostat

a. Anesthetize.

b. Use #11 blade scalpel to cut down to the barb.

c. Grab barb with hemostat.

c. Pull entire fishhook up and out.

Post-Removal Care

1) Check for foreign bodies: Consider xray if any concern for retained objects.

2) Tetanus: Hit them with that tdap as indicated. 

3) Antibiotics: No trials have been done to study PO antibiotics after fishhook injury. You might consider adding on systemic antibiotics for immunocompromised folks, infection-prone areas, or contaminated hooks. At the very least, topical bacitracin and instructions on local wound care are always a good call.

Happy fishing,

Kelsey

Resources:

1) https://www.aliem.com/trick-fishhook-removal-techniques/

2) https://www.uptodate.com/contents/fish-hook-removal-techniques?search=fish%20hook%20removal&source=search_result&selectedTitle=1%7E1&usage_type=default&display_rank=1#H13

3) https://www.tampaemergencymedicine.org/blog/fish-hook-removal

4) https://www.emra.org/emresident/article/angling-for-success-techniques-for-fishhook-removal-in-the-ed

5) https://www.emrap.org/episode/ucprocedures/ucproceduresfishhookremoval

6) https://www.emrap.org/episode/fishhookremoval1/fishhookremoval1

7) https://www.emrap.org/episode/fishhookremoval/fishhookremoval

Soft Tissue Foreign Body

General

·      Transient inflammation is an integral part of normal wound healing.

·      Foreign debris in a wound provokes an inflammatory response in an effort to eliminate or contain the invader.

·      Large quantities of devitalized tissue, foreign debris, bacteria, or other irritants present within a wound intensify this protective response.

·      Prolonged or intense inflammatory responses delay wound healing and destroys surrounding tissue and bone.

·      If the body can’t dissolve or dispose of foreign material, it gets encapsulated within a fibrous capsule.

·      Type of foreign body can make a difference in the inflammatory reaction

o   Inert Material (glass, metal, plastic) may have no abnormal tissue response. Some metals may have oxidizing properties that can cause minor inflammation.

o   Vegetative Material (wood, thorns, spines) trigger SEVERE inflammatory reactions.

o   Marine material (sea urchin spines) can cause chronic inflammation with granuloma formation.

·      Infections are the most common complication of retained objects.

o   Typically, they can be resistant to therapies such as antibiotics, anti-inflammatory drugs, and steroids.

o   Some infections will resolve spontaneously once the foreign body is removed.

o   Vegetative foreign bodies may also cause fungal infections, particularly in immunosuppressed patients.

o   Chronic, delayed, and recurrent infections are associated with retained foreign bodies

Physical Exam

·      Make effort to visually inspect all recesses of a wound.

·      Wounds deeper than 5 mm and wounds whose depth cannot be visualized have a higher association with foreign bodies.

·      If punctures and other narrow wounds make direct visualization difficult and there is concern about a foreign body below the surface, the wound margins should be extended with a scalpel.

·      Blind probing with a hemostat is a less effective but sometimes is an acceptable alternative to wound exploration when the wound is narrow and deep and extending the wound is not desirable.

·      A closed hemostat should be introduced into the wound and either used as a probe or spread open and then withdrawn.

·      If an instrument strikes a metallic or glass foreign body, it will produce a grating sensation.

Imaging

·      Beneficial to obtain post removal imaging of multiple foreign bodies to ensure all pieces were found

Localizing Techniques

·      It’s easier to detect the presence of a foreign body than to locate its exact position.

·      If radiopaque, can estimate location and depth by taping radiopaque skin markers such as paper clips on skin at wound entrance or directly above the object.

·      Another method is using hypodermic needles, two or three needles inserted into skin near the object after anesthetizing the area at 90 degrees to each other to create a frame of reference.

·      Almost all glass is visible on radiographs if it is 2 mm or larger, and glass does not have to contain lead to be visible on plain films

·      Ultrasound can identify a wide variety of soft tissue foreign bodies such as wood, fish bones, sea urchin spines, other organic material, fiber, and plastic, with >90% sensitivity for foreign bodies >4 to 5 mm

o   Foreign bodies appear as hyperechoic foci, usually with acoustic shadowing extending distally.

o   A hyperechoic rim, or halo sign, indicates an abscess or granuloma around the object.

o    Sonography can estimate the depth of a foreign body below the skin surface and guide object removal in real time.

Treatment

·      Not all foreign bodies must be removed, and not all that require removal must be extracted in the ED 

·      Thorns, spines, wood splinters, and other vegetative materials should be promptly removed because they cause intense and excessive inflammation.

·      Heavily contaminated objects such as teeth and soil covered objects should be removed ASAP.

·      Antibiotics treatment CANNOT replace foreign body removal.

·      Glass, metal, and plastic are relatively inert, and removal can be postponed, if necessary.

o   Glass foreign bodies in hands or feet can cause persistent pain with gripping or walking, and they can sever nerves or tendons years after the initial injury.

o   Deep, sharp foreign bodies in these locations should be referred to appropriate specialists for eventual removal.

·      Use adequate anesthetics to achieve pain control, good lighting, and tourniquets if needed.

·      Although most foreign bodies in hands should be removed because the hand is mobile and sensitive, deep exploration of the hand by the emergency physician is not recommended because knowledge and experience are needed to avoid injury to numerous closely spaced vital structures.

Post Removal Treatment

·      After removal irrigate wound thoroughly

·      In general, if concern for contaminated puncture wound, then enlarge entrance wound to allow for more effective cleaning.

·      Post procedure x-ray if multiple objects removed

·      Update tetanus

·      Wounds in which all foreign contaminants can be removed and those in locations with good blood supply can be closed primarily. Otherwise, delayed primary closure is preferred.

·      NO PROVEN BENEFIT FOR PROPHYLACTIC ANTIBIOTICS FOR UNINFECTED WOUNDS CONTAINING FOREIGN BODIES

·      Antibiotics are justified for infected wounds, particularly when removal must be postponed

·      Delayed removal – refer to surgeon or interventional radiologist for delayed removal of foreign bodies.

o   If a foreign body is near a joint or highly mobile region, the affected area should be splinted before removal to prevent further injury or migration of the object.

References

Tintinallis Emergency Medicine A Comprehensive Study Guide 

https://www.aafp.org/afp/2007/0901/p683.html

http://www.emdocs.net/soft-tissue-foreign-bodies-ed-presentation-evaluation-and-management/