It’s No Fish Tale – These Uncommon Hand & Upper Extremity Fishing Injuries Can Really Happen!

Located on the Gulf of Mexico and home to hundreds of lakes, it’s no wonder that the Texas coast is the playground to fishing enthusiasts far and wide.

Barracuda

unhook stingray2But even the seasoned sportsman can fall victim to some unlikely fishing injuries affecting the hand and upper extremity. In fact, fishermen (and women) put themselves in danger every time they come into contact with marine life – unpredictable behavior/aggressive and often forceful nature of a catch, prevalence of less commonly treated bacteria, unsanitary tools/equipment, poor wound care – all contributing to some common and not so common injuries that hand specialists see in a region like the Texas Gulf Coast.

Some common fishing injuries and conditions with which a Texas hand surgeon is all too familiar include:

fillet_2Many of these common injuries and conditions are treated non surgically and follow the same treatment protocol as any other patient with the same diagnosis – regardless of the cause.

Uncommon Hand & Upper Extremity Fishing Injuries and Conditions

Though there is very little that surprises a hand specialist practicing in “sportsman’s paradise,” an unusual injury associated with fishing will occasionally make its way to a Texas medical clinic.

Some of these uncommon injuries and conditions include:

  • Sting Ray Laceration
  • Fish Bite / Impalement
  • Fish Handler’s Disease / Bacterial Infection
  • Lodged Fish Bones, Fin Spine 

Unlike other injuries that break the skin, these types of fishing injuries are particularly concerning.  Fish and other marine life carry bacterial infections within their bodies, as well as on their skin, which can affect humans if certain precautions are not taken immediately. Some types of bacteria found in marine life are not commonly seen and do not respond to conventional antibiotics frequently used for infections.

Additionally, some marine life such as the Sting Ray utilize defense mechanisms that require special attention when used against a fisherman.

Sting Ray Laceration
While many sting ray injuries involve an inadvertent encounter between a foot or other lower extremity and a sting ray’s barb, some have occurred to the hand or wrist while trying to remove a sting ray from a fishing net or line.

These types of lacerations require more than bandaging.  Not only do sting ray barbs pierce like a weapon, all sting rays are armed with at least one serrated venomous spine at the base of their whip-like tail.  Short-tail sting rays have two tail spines: a slender spike in front of a large, jagged bayonet (1).

In addition to possible damage to muscle, tendons and nerves that can occur from the physical impalement of a sting ray barb, its venom is comprised of many different substances that can cause tissue to break down and die.
Some of the symptoms that Sting Ray venom can cause include:

 

  • Immediate and severe pain radiating up the affected limb
  • Bleeding and swelling in the affected area
  • Sweating
  • Faintness, dizziness and weakness
  • Low blood pressure
  • Salivation, nausea, vomiting, diarrhea
  • Headache
  • Shortness of breath (2)

 

Medical attention is recommended for all sting ray injuries.  Minimally, the wound will be cleaned with warm water to remove the venom and a tetanus booster given if it has been more than five years since the last tetanus booster. Tetanus prevention is required if the patient has never had a tetanus vaccination.  Antibiotics may also be required, and depending on the severity of the injury and amount of damage sustained (often the result of the delay in seeking treatment), surgical intervention to repair soft tissue damage and/or a period of rehabilitation may be required to restore strength to the injured limb (2).

Fish Bite and Impalement
While not every fish injury comes with a venomous double blow, the high risk of bacterial infection and soft tissue damage can be just as serious.  Many fish have sharp teeth, tails and pointed features that can easily break the skin.  Wrestling the unwilling catch onto the boat or beach can leave some sportsmen a bit worse for the wear.

 

Aside from the bacterial concerns that come with marine life, the forceful impact from a sharp feature of the fish can result in soft tissue damage that may require surgical repair and/or months of rehabilitation to restore hand and upper extremity function – as the hand alone is comprised of approximately 34 muscles, 120 known ligaments, and 50 nerves!

 

These types of deep puncture wounds or lacerations in the hand are also at high risk of infection and should be monitored closely.  A delay in the appropriate treatment can lead to complicated tenosynovitis and horseshoe abscess.  Additionally, marine life bacterial infections resulting from Mycobacterium marinum (M. marinum) do not respond to some conventional antibiotic treatment such as amoxicillin (3).

Fish Handler’s Disease
Not every fishing-related Mycobacterium marinum infection is the result of an obvious injury/wound.  A condition known as Fish Handler’s Disease can impact those frequently handling fish and generally affects the hands.  Any inconspicuous cut or small opening on the skin can allow the bacteria to enter the body.  The bacteria’s inability to proliferate in the warm body confines it to the affected area.

 

Common symptoms include swelling, tenderness, and bluish-purple spots. Fish Handler’s Disease is treated with special antibiotics used specifically for this type of bacterial infection.  Recovery can take months.

Lodged Fish Bones, Fin Spine
Occasionally in the handling of fish a fish bone or fin spine can lodge in the hand. Though this may not be painful or immediately worrisome to the injured party, these types of injuries are concerning.  Such injuries often leave residual fragments of foreign organic matter in the soft tissue, which can cause secondary infections such as Staphylococci and Streptococci (4).

 

Typically, x-rays are used first to try and identify a foreign body in the tissue, though are not always successful in doing so.  An MRI may be indicated to identify fine fin spines and tiny bones lodged in the body’s tissue. The surgical removal of the foreign body is important.  Failure to seek and remove the foreign body may lead to persistence of infection (4). Multiple surgical procedures may be required, and the patient is put on antibiotics to prevent infection. Physical therapy may be required after surgery to regain mobility of the hand.

 

If this type of injury goes untreated it can result in permanent disability and hospitalization for infection. Though the area may look as if it has healed, but is still tender, swollen, discolored, or abnormal in any way, individuals are urged to see a hand specialist.

 

Prevention and Precaution
Understanding the unique aspects of the marine life occupying the waters you’re sporting and utilizing protective gloves and garments while fishing can go a long way in injury prevention.  As the largest organ of the human body, our skin serves as a protective barrier.  When any area is compromised, our entire body is compromised. Individuals with other health conditions, such as diabetes or immune deficiency disorders should be particularly cautious and consult a hand specialist for proper wound care.

If not addressed properly, even seemingly minor fishing injuries can result in serious infection, lingering weakness or permanent disability – inhibiting participation in the sport you love.

 

References

 

Ring Avulsion, a Traumatic Finger Injury

Recently talk show host Jimmy Fallon explained to his audience how a seemingly minor fall nearly cost him a finger – shedding light on a rare yet serious finger trauma known as a Ring Avulsion injury.

Ring avulsion results from the mechanism of crushing, shearing and avulsion, inducing severe macroscopic and microscopic damage. This type of injury often occurs when a ring that an individual is wearing is caught on an object, usually during a fall or jump.  It can also occur when caught on fast moving equipment or just simply in a “freak” accident.

Damage from the abrupt and often harsh tug of the caught ring can range from a simple contusion to “degloving” of soft tissue – pulling the skin off circumferentially and stripping away the nerves, tendons and bone. Severe accidents may result in traumatic amputation of the finger.

Ring avulsion can be among one of the most devastating traumatic finger injuries, as often replantation following severe soft tissue damage is not possible – requiring revision amputation.

Fortunately, advances in microsurgery and interposition graft techniques have improved results with ring avulsion replantation.  Patients should see a hand specialist immediately after the injury is identified.

Symptoms of Ring Avulsion

While Fallon knew he had severely injured his finger in his fall, the extent of the damage and seriousness of the injury was not completely revealed until his examination and x-ray.  Prompt attention and surgical care from a specialized hand team fortunately saved his finger.

The severe damage that can occur in a ring avulsion case is not always evident to a patient. Immediate examination and x-ray assessment are necessary.

Symptoms may include:

  • Pain
  • Bleeding
  • Lack of sensation at the tip
  • Disfigurement
  • Finger discoloration or whitening

In severe cases, part of the finger is removed from the bone or completely severed (traumatic amputation).

Diagnosing and Treating Ring Avulsion

When a patient presents with this type of finger trauma, the wound is cleaned and inspected for visible avulsed vessel, nerve, and tendon.  Damaged skin edges are also assessed.  An x-ray may also be indicated before determining the type of avulsion a patient has incurred.  If a portion of the finger is separated, an x-ray is performed on both the amputated part and the remaining digit to fully asses damage and likelihood of replantation.

If there is a separated part, it is wrapped in a saline gauze and placed in a bag with ice water.  The patient is given antibiotics and tetanus prophylaxis.

The injury is then classified using one of several ring avulsion classification systems that exist.  Most commonly used is the Urbaniak Classification system.  The class of ring avulsion (Class 1, 2, or 3) will help determine treatment.

The goal of the hand surgeon is to salvage, maintain function and, if possible, provide an esthetic appearance.

Commonly used classification chart for Ring Avulsion injuries.

Commonly used classification charts for Ring Avulsion injuries.

Avoiding Risk of Ring Avulsion

It is difficult for patients to understand how otherwise inconsequential stumbles or movements can result in the damage or loss of a digit when a ring is involved.  We often forget that the bones and joints of the hand and wrist are small and capable of sustaining just so much force. Skin is the finger’s strongest part.  Once the skin tears, the remaining tissue quickly degloves. Though rare, the potential harm that a ring can pose should be considered – particularly when performing certain extracurricular or sports activities, or when working with machinery. Unfortunately many accidents resulting in a ring avulsion are not anticipated nor could be imagined.  Prompt attention is key to a successful outcome.

References

Flagg SV, Finseth FJ, Krizek TJ. Ring avulsion injury. Plast Reconstr Surg. 1977;59:241–8.

Brooks D, et al. Ring avulsion: injury pattern, treatment, and outcome. Clinics in Plastic Surgery April 2007 ;34(2):187-95, viii.

Fejjal N, Belmir R, Mazouz S El, Gharib NE, et al. Finger avulsion injuries:  A report of four cases.  Indian J Orthop. 2008 Apr-Jun; 42(2): 208–211.

Sears ED, Chung KC.  Replantation of finger avulsion injuries:  A systematic review of survival and functional outcomes.  J Hand Surg Am. 2011;36(4):686-94.