Needlefish injuries, commonly reported in the Indo-Pacific region, have not been previously reported along the European coastlines. This case report describes a penetrating injury to the heel of a professional surfer during competition off the Portuguese coast. Diagnostic as well as therapeutic recommendations are made.
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Reports of hazardous marine animals have increased over the last two decades.1,2 Along the European seaboard, stingrays and catfish commonly cause penetrating injuries, but there are no reports of injury by needlefish. Human injuries by needlefish result from the ability of the fish to leap out of the water at high speed. Injury occurs by impalement of the needlefish beak. This produces a stab wound, often with the beak intact. Injuries by needlefish, especially among windsurfers, divers, and fisherman, have only been reported in New Caledonia,3 Papua-New Guinea,4 the Red Sea,5 and Hawaii.6 This case report describes a penetrating injury to the heel caused by a needlefish, which occurred during a professional surf contest in European waters. Management of the injury is discussed.
A 25 year old man presented to the emergency department of our hospital with persistent swelling and pain in his right heel. Two weeks before, while riding a wave in a professional competition off the coast in Portugal, he had suddenly felt a violent thump and pain in his right heel. The sharp pain and profuse bleeding caused him to be thrown off the wave and return to shore. On arrival in the Portuguese emergency ward, initial evaluation revealed a foreign body sticking out of the right heel. The doctor removed the protruding part of the foreign body and bandaged the wound. Thereafter the patient was discharged from further care.
Two days later, on return to the Netherlands, the heel was still warm, swollen, and painful. Consultation with the patient’s general practitioner and sports medicine doctor resulted in prescription of rest and antibiotics (flucloxacillin 500 mg four times a day) for seven days. After the antibiotic course had been completed, the swelling and pain persisted although there was no fever. Three days later the patient presented to the emergency department. Initial evaluation showed a painful, inflamed, fluctuating swelling at both the medial and lateral side of the right heel. The lateral wound produced a small amount of pus. Body temperature was 37.1°C.
The presence of a foreign body was noted on a standard lateral radiograph of the heel. This was seen as opacity at the cranial border of the posterior part of the calcaneus. This opacity was shaped as two dense parallel lines (fig 1). With the clinical characteristics and our anamnestic experience, a fish wound was suspected. The fish was found to be a needlefish, a member of the Belonid family (fig 2). The patient was operated on the same day.
The patient underwent surgical exploration of the lateral and medial side of the right heel with removal of the fish remnants and careful debridement (fig 3). Antibiotics were not prescribed, because all the foreign body had been removed. The wound was left to heal by secondary intention. The wound was dressed with wet gauze and flushed twice daily. The patient was kept in hospital for two days, and immediate improvement was seen. There were no complications. Four weeks after the accident, the patient had resumed his professional activities.
Take home message
Penetrating injuries by needlefish require surgical intervention. The use of antibiotics is optional.
Needlefish belong to the Beloniform order which is composed of two families, the Belonids and the Hemiramphids. These are found in (sub) tropical waters of all oceans. The fish are long and slender, ranging in length from 0.5 m to more than 1.5 m. The long, narrow “beak” is comprised of jaws filled with sharp, little teeth. The colour, bluish green on top and silver on the bottom, is adapted for surface dwelling. Needlefish are surface carnivore predators.
Needlefish injury should not be confused with a stingray or catfish injury; all three fish produce penetrating injuries. However, stingray and catfish are bottom dwellers. Injury by a stingray typically occurs when it is stepped on or handled. Catfish injuries generally occur only while handling the fish. Both stingray and catfish cause injury with envenomation, which should be treated by immersion in hot water. Management of the wound is similar for all three.
A needlefish injury should be treated like a stab wound. The small diameter of the fish’s snout allows it to penetrate between bony structures of the thorax, spinal canal, and skull.4 Abdominal, ocular, and articular injuries have also been described.3 After penetration of the skin, the beak can break into several fragments and inflict severe damage at a distance from the entry point. Standard radiographs are recommended to determine the presence of retained beak. The appearance of two semiparallel lines of opacity is typical of a needlefish beak. Radiographic and clinical evaluation lead to diagnosis and early surgical treatment.
There are no prospective studies providing evidence for optimal antibiotic selection for marine acquired infections or prophylaxis. Immunocompetent patients do not always require prophylaxis. A surgical debridement is the mainstay of treatment. Tetanus prophylaxis is required if not up to date. Wounds generally should be left to heal by secondary intention.
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