What are the immediate steps to take after a stingray sting. How can you alleviate the severe pain caused by a stingray injury. What are the potential complications of a stingray sting and when should you seek emergency medical care. How can you prevent stingray stings while enjoying beach activities.

Understanding Stingray Stings: Causes and Symptoms

Stingrays, those flat, disk-shaped creatures with wing-like fins, inhabit both saltwater and freshwater environments. While generally known for their gentle nature, stingrays can deliver a powerful and incredibly painful sting when disturbed or accidentally stepped on. Their long, whip-like tails contain one or more barbed spines covered by a sheath, each loaded with venom.

The incidence of stingray stings along North American coasts has varied over time, with historical estimates of around 750 cases per year. However, current figures are uncertain as many cases go unreported. These injuries typically occur when unsuspecting swimmers wade through shallow waters, unknowingly stepping on a stingray buried in the sand. This provokes the animal to thrust its tail upward and forward, driving the venomous spine into the person’s foot or leg.

Primary Symptoms of a Stingray Sting

• Immediate and severe pain at the wound site
• Pain may spread rapidly, peaking within 90 minutes
• Discomfort can persist for 6 to 48 hours, occasionally lasting days or weeks
• Syncope (fainting)
• Weakness
• Nausea
• Anxiety

These symptoms are often accompanied by peripheral vasodilation, which may contribute to the overall discomfort. In some cases, more severe reactions can occur, including lymphangitis, vomiting, diarrhea, sweating, generalized cramps, inguinal or axillary pain, and respiratory distress. While rare, fatalities have been reported.

Immediate First Aid for Stingray Stings

When faced with a stingray sting, prompt action is crucial to minimize pain and prevent potential complications. The following steps outline the immediate first aid measures to take:

1. Remain in the ocean if possible, allowing salt water to cleanse the wound
2. Apply pressure to the wound to slow bleeding
3. If the barb is superficially embedded and not in a critical area, carefully remove it
4. Gently irrigate the wound with salt water to remove any fragments of spine, glandular tissue, or integument
5. Seek medical attention, especially if the wound is deep or in a sensitive area

Is warm water immersion effective for treating stingray stings? While some experts recommend this method, its efficacy as an early treatment has not been conclusively verified. It’s essential to focus on the proven first aid steps before considering additional remedies.

Medical Treatment and Wound Care

Upon reaching a medical facility, the treatment for a stingray sting involves several key steps:

• Thorough examination of the wound for remnants of the stingray’s sheath
• Debridement of the affected area
• Administration of local anesthetic as needed
• Removal of any embedded spines, treating them similarly to other foreign bodies
• Close evaluation for potential puncture of viscera in cases of trunk injuries
• Supportive treatment for systemic manifestations
• Tetanus prophylaxis administration
• Elevation of the injured extremity for several days

Depending on the severity of the wound, antibiotics may be prescribed, and surgical wound closure might be necessary. It’s crucial to monitor the wound closely for signs of infection during the healing process.

Characteristics of Stingray Wounds

Stingray stings result in distinctive wound characteristics that require specific attention:

• Jagged appearance
• Profuse bleeding
• Frequent contamination with parts of the integumentary sheath
• Discoloration of wound edges
• Potential localized tissue destruction
• Presence of swelling
• Susceptibility to infection

Why do stingray wounds have these particular features? The jagged nature of the wound is due to the serrated edge of the stingray’s barb. The contamination occurs as the barb, covered in a protective sheath, breaks off in the victim’s tissue. This foreign material, combined with the venom, leads to the discoloration and potential tissue damage observed around the wound site.

Preventing Stingray Stings: The Stingray Shuffle

While stingray stings can be painful and potentially dangerous, they are largely preventable. One of the most effective methods for avoiding these injuries is the “stingray shuffle.” This technique involves shuffling your feet along the ocean floor rather than taking normal steps when wading in shallow waters.

How to Perform the Stingray Shuffle:

1. Enter the water slowly
2. Keep your feet close to the sand
3. Slide your feet forward in a shuffling motion
4. Maintain constant contact with the ocean floor
5. Move slowly and deliberately

Why is the stingray shuffle effective? This method works because it alerts nearby stingrays to your presence, giving them time to swim away. Stingrays are not aggressive and will typically avoid human contact if given the opportunity. The shuffling motion creates vibrations in the water that stingrays can detect, prompting them to move before you accidentally step on them.

Long-term Effects and Complications of Stingray Stings

While most stingray stings heal without significant long-term consequences, some cases can lead to more serious complications. Understanding these potential outcomes is crucial for proper management and follow-up care.

Possible Long-term Effects:

• Chronic pain at the injury site
• Nerve damage
• Tissue necrosis
• Scarring
• Infection, including rare cases of tetanus
• Allergic reactions to stingray venom

Can stingray stings cause permanent damage? In most cases, with proper treatment, stingray stings do not result in permanent damage. However, severe cases or those involving critical areas of the body can potentially lead to lasting effects. Nerve damage, for instance, may cause prolonged sensory disturbances or weakness in the affected limb.

Infections are a significant concern with stingray injuries. The marine environment harbors various bacteria that can easily contaminate the wound. In rare cases, these infections can progress to more serious conditions such as cellulitis or even sepsis if left untreated.

When to Seek Emergency Medical Care for Stingray Stings

While many stingray stings can be managed with first aid and follow-up care, certain situations require immediate emergency medical attention. Recognizing these scenarios is crucial for preventing potentially life-threatening complications.

Seek Emergency Care If:

• The barb has penetrated the neck, throat, abdomen, or chest
• The spine has completely pierced through a part of the body
• There is severe bleeding that doesn’t stop with direct pressure
• You experience difficulty breathing or chest pain
• Signs of a severe allergic reaction appear, such as swelling of the face or throat
• The pain is unbearable or spreads rapidly beyond the sting site
• You develop a fever or signs of infection (redness, swelling, warmth around the wound)

Why is immediate medical attention crucial in these cases? Stings to critical areas like the neck or abdomen can potentially damage vital organs or major blood vessels. Complete penetration of the barb may require surgical intervention for safe removal. Severe allergic reactions, while rare, can rapidly progress to anaphylaxis, a life-threatening condition requiring immediate treatment.

The Role of Venom in Stingray Injuries

Understanding the nature and effects of stingray venom is crucial for appreciating the severity of these injuries and the importance of proper treatment. Stingray venom is a complex mixture of various bioactive compounds, each contributing to the intense pain and potential systemic effects observed in sting victims.

Key Components of Stingray Venom:

• Serotonin
• 5-nucleotidase
• Phosphodiesterase
• Proteolytic enzymes

How does stingray venom cause such intense pain? The combination of these components works synergistically to produce the characteristic symptoms of a stingray sting. Serotonin, for instance, is a potent vasoconstrictor that can cause intense local pain. The enzymes in the venom can break down tissues, leading to localized necrosis and prolonging the healing process.

The venom’s effects are not limited to the immediate area of the sting. As it enters the bloodstream, it can cause systemic reactions such as nausea, vomiting, and in severe cases, cardiovascular effects. This is why monitoring for systemic symptoms is crucial in the aftermath of a stingray injury.

Interestingly, the potency of stingray venom can vary between species and even individual stingrays. Factors such as the size of the stingray, the depth of penetration, and the amount of venom injected all play a role in determining the severity of the injury.

Psychological Impact of Stingray Injuries

While the physical effects of stingray stings are well-documented, the psychological impact on victims is often overlooked. The sudden, intense pain and the potential for serious complications can lead to significant emotional and psychological responses that may persist long after the physical wound has healed.

Common Psychological Reactions:

• Anxiety about returning to the ocean
• Post-traumatic stress symptoms
• Heightened fear of marine creatures
• Depression related to prolonged pain or disability
• Anger or frustration during the recovery process

How can victims cope with the psychological aftermath of a stingray injury? Mental health professionals recommend several strategies:

1. Seeking support from friends, family, or support groups
2. Practicing relaxation techniques to manage anxiety
3. Gradually re-exposing oneself to beach environments
4. Educating oneself about marine life and safety practices
5. Considering professional counseling if symptoms persist

It’s important to recognize that these psychological reactions are normal responses to a traumatic event. Addressing both the physical and emotional aspects of recovery can lead to a more complete healing process and help prevent long-term phobias or anxiety related to ocean activities.

For some individuals, a stingray encounter can even lead to a newfound interest in marine biology or conservation efforts. This positive reframing of the experience can be a powerful tool in overcoming trauma and developing a healthier relationship with the ocean environment.

Stingray Stings – Injuries; Poisoning

By

Robert A. Barish

, MD, MBA, University of Illinois at Chicago;

Thomas Arnold

, MD, Department of Emergency Medicine, LSU Health Sciences Center Shreveport

Reviewed/Revised Jan 2022 | Modified Sep 2022

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Topic Resources

Stingrays once caused about 750 stings/year along North American coasts; the present incidence is unknown, and most cases are not reported. Venom is contained in one or more spines on the dorsum of the animal’s tail. Injuries usually occur when an unwary swimmer wading in ocean surf, bay, or backwater steps on a stingray buried in the sand and provokes it to thrust its tail upward and forward, driving the dorsal spine (or spines) into the patient’s foot or leg. The integumentary sheath surrounding the spine ruptures, and the venom escapes into the patient’s tissues.

The main symptom of a stingray sting is immediate severe pain. Although often limited to the injured area, the pain may spread rapidly, reaching its greatest intensity in &lt 90 minutes; in most cases, pain gradually diminishes over 6 to 48 hours but occasionally lasts days or weeks. Syncope, weakness, nausea, and anxiety are common and may be due, in part, to peripheral vasodilation. Lymphangitis, vomiting, diarrhea, sweating, generalized cramps, inguinal or axillary pain, respiratory distress, and death have been reported.

The wound is usually jagged, bleeds freely, and is often contaminated with parts of the integumentary sheath. The edges of the wound are often discolored, and some localized tissue destruction may occur. Generally, some swelling is present. Open wounds are subject to infection.

Stingray stings to an extremity should be gently irrigated with salt water in an attempt to remove fragments of spine, glandular tissue, and integument. The spine should be removed in the field only if it is superficially embedded and is not penetrating the neck, thorax, or abdomen or creating a through-and-through injury of a limb. Significant bleeding should be staunched with local pressure. Warm water immersion, although recommended by some experts, has not been verified as an effective early treatment for stingray injuries.

In the emergency department, the wound should be reexamined for remnants of the sheath and debrided; a local anesthetic may be given as needed. Embedded spines are treated similarly to other foreign bodies. Patients stung on the trunk should be evaluated closely for puncture of viscera. Treatment of systemic manifestations is supportive. Tetanus prophylaxis should be given (see table ), and an injured extremity should be elevated for several days. Use of antibiotics and surgical wound closure may be necessary.

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Bites, First Aid, Symptoms, and Treatment

Stingrays are flat, disk-shaped creatures with fins that resemble wings. Species of stingray can be either saltwater or freshwater. They’re most often associated with tropical ocean climates, and their sting is a commonly reported beachgoer injury.

A stingray’s tail is long, thin, and tapered, much like a whip. In the middle of the tail are one or more barbed spines covered by a sheath. Each spine contains venom, and the stingray’s tail can pack a powerful, incredibly painful sting.

Stingrays generally aren’t dangerous — in fact, they have a reputation for being gentle. They often burrow beneath the sand in the shallows and swim in the open water. Stingrays will usually only sting when disturbed or stepped on by unaware swimmers.

Most of the time, you can avoid being stung by a stingray. But if you do experience a stingray sting, there are several things you can do immediately to start relieving the pain.

When stung by a stingray, you’ll feel immediate, severe pain at the wound site. You need to begin treating the wound right away if it’s superficial.

If the barb has punctured your throat, neck, abdomen, or chest, or has pierced completely through part of your body, don’t attempt to remove it. Seek emergency medical attention immediately.

Otherwise, remain in the ocean and pull the barb out if you can. Allow the salt water to clean the wound while applying pressure over it to both slow the bleeding and encourage the venom to come out.

Try to clear out any additional debris you might see in the cut or puncture while you’re still in the water.

Pay close attention to how you feel in the sting’s aftermath. It’s possible to have a life-threatening allergic reaction to stingray venom, which requires emergency medical care. Expect the area to swell.

Hot water kills stingray venom and may relieve the pain associated with the sting. Once you’ve determined you’re not having an allergic reaction, you might want to try soaking the sting in hot water.

The ideal temperature for a soak is 110°F to 115°F (43°C to 46°C). Reheat your water every 10 minutes to keep it continually hot, and soak the wound for 30 to 90 minutes, or as long as it takes for the pain to subside. The hot water may also draw out venom, which resembles jelly.

Once you’ve relieved the pain, apply antibiotic ointment or cream to the wound and cover it with gauze.

If you’re stung by a stingray, you may experience these symptoms:

• abdominal pain
• anxiety
• bleeding
• diarrhea
• dizziness
• extreme pain at the wound site
• fatigue
• headache
• low blood pressure
• muscle cramps
• nausea
• necrosis (death) of surrounding tissue
• pain in the extremities
• painful, swollen lymph nodes near the site
• skin discoloration
• swelling
• vomiting

The following symptoms could be signs of a systemic reaction or respiratory distress and require immediate emergency medical care:

• fainting
• irregular heartbeat
• muscle paralysis
• seizures
• shortness of breath
• sweating

It’s possible for the heart to stop or for the body to go into shock after a stingray sting. Some people have died as a result of stings in their chests and abdomens.

If you have a puncture wound and aren’t up to date on your tetanus booster, it’s time to get it renewed.

If you’ve had the wound for a while but are slow to recover, you experience redness or additional swelling at the site, or the site begins to ooze pus, get treatment right away. The site may be infected, and your doctor may prescribe antibiotics (oral or intravenous) to treat it.

Because stingrays camouflage themselves under sand to hunt for prey, they can be hard to spot and easy to step on if you don’t know what to look for.

Once it’s been threatened, a stingray will whip its tail in defense — which can reach up and over its head — leaving a laceration or puncture wound in your skin.

When a stingray whips its tail at you, one or more of its spines may pierce your skin. The sheath around each spine then breaks apart and releases venom into the wound and surrounding tissue.

Stingrays most often sting people in their feet, ankles, and legs, but sometimes a sting may occur elsewhere on the body.

To avoid a stingray sting, shuffle your feet in the sand as you wade through shallow water. This will give stingrays a warning that you’re coming their way. Another option is to throw shells or small rocks into the water ahead of you as you wade.

If you do seek emergency medical care, your healthcare providers will closely inspect your wound. They will need to remove any debris left in the wound from the spines or the sheath.

They may take X-rays of the sting site to determine whether all the debris has been cleared. Spine and sheath fragments are visible on an X-ray.

You might receive an antibiotic via prescription or IV, as well as stitches if the wound is large or deep. You may also receive a tetanus booster.

In some cases, you might require surgery after a stingray sting to remove dead tissue or to repair a severe wound.

For most people, stingray stings heal within a few weeks. Expect localized numbness and tingling around the wound site during the healing period.

Location of the sting, amount of venom in the tissue, extent of tissue damage, and promptness of treatment will affect healing time. If you have to undergo surgery after the sting, your recovery will take more time.

What to do if you get bitten by a stingray

Contents

1. How to protect yourself from contact with a stingray
2. What are the consequences of a stingray
3. What should not be done if a stingray is stung
4. What measures can be taken if a stingray is stung
5. Interesting facts about rays Stingrays

Stingrays are a family of cartilaginous fish that belongs to the order Stingrays. They live in almost all seas and oceans. They feel great in a very wide temperature range, ranging from 1.5 ° C to 30 ° C. Some species are common in shallow water, others are found at depths up to 2500 meters. There are even stingrays that prefer to live in fresh water.

Stingray

Stingrays have a well-defined tail, which looks like a whip. Its length in some species exceeds half the total length of the fish. The tail ends with one or two serrated spikes, along which furrows with poisonous glands often run. The length of the spike can reach up to 37 cm. Thanks to the powerful muscles of the tail and the exceptionally hard spikes, the stingray can easily pierce a wetsuit, a leg, and the bottom of a wooden boat.

It is noteworthy that the stingray uses its tail exclusively for self-defense, since its more than modest teeth are completely unable to cope with such protective functions. When danger arises, the stingray stingray makes sharp lunges up and forward with its tail, and the spike pierces the enemy.

How to avoid contact with the stingray

Stingray spike tip

First, in areas where stingrays spread, enter the water gradually, do not sneak, scuff along the bottom with your feet to scare off the hunter, who may burrow into the sand waiting for a suitable lunch. Be especially careful in shallow bays, river mouths, near beaches, that is, in places that stingrays choose for themselves to hunt.

Secondly, swim in special shoes.

Third, do not enter the water at night.

Fourth, be vigilant while diving, do not tease or pester stingrays.

Fifth, when you find a stingray, make some noise, wave your leg several times under water, try to scare it away.

Sixth, carefully butcher the carcass of the stingray when using it for culinary purposes. The poison of even a dead stingray continues to pose a danger to humans.

What are the consequences of a stingray

Stingray venom has a neurotropic effect, causes instant burning and throbbing pain in the damaged area, the peak of which is observed after 1-1.5 hours. Painful sensations can persist for several days, gradually fading over the next 6-48 hours. They are so pronounced that the victims begin to scream, rush about. In such cases, even loss of consciousness is possible.

Contact with a stingray, in addition to pain, is also accompanied by the following symptoms:

• pallor and subsequent redness or blueness of the skin around the wound,
• nausea,
• dizziness,
• chills,
• drop in blood pressure,
• sudden increase in heart rate,
• the appearance of a feeling of anxiety.

Skate in the water

Less commonly, lymph nodes may swell, sweating may increase, pain in the groin and armpits, vomiting and diarrhea may occur. In severe cases, there is a high probability of convulsions, respiratory failure, the victim may become delirious, lose consciousness.

The greatest danger is represented by large individuals, which have a large amount of poison and a powerful thorn. The lethal outcome is observed mainly when injured in the chest or abdomen.

Plus, the stingray’s barb usually causes a laceration that bleeds profusely. Fragments of its coating can remain in the wound, thereby increasing the risk of infection. In this case, the color of the edges of the wound often changes, tissues are destroyed, and pronounced edema appears.

What not to do when stinging a stingray

Under no circumstances should you jerk out fragments of a spike stuck in a wound. If removed incorrectly, the teeth on the spike can cause additional injury to the victim.

Do not cut the wounds either. Such actions do not ensure the removal of poison, but only unnecessarily injure the victim.

It is not recommended to cauterize the damaged area, as this is fraught with the same unfortunate consequences that were discussed in the previous paragraphs.

Do not inject a solution of potassium permanganate or any other strong oxidizers into the wound.

It is forbidden to drink alcoholic beverages, which only aggravate the situation, accelerating the spread and absorption of the poison.

What measures can be taken in case of a stingray

While waiting for a doctor or on the way to the nearest medical facility, the victim can and should be given first aid.

1. First of all, suck out the poison from small puncture wounds for the first 10 minutes after the injection, spitting it out periodically. This can be done only in the absence of any damage in the oral cavity of the sucker. At the end of the procedure, the mouth must be rinsed with a solution of potassium permanganate or simply clean water.

2. To reduce the concentration of poison and relieve pain, the wound should also be washed with sea water in large quantities.

3. Then carefully remove the remaining pieces of the stud that point backwards. In this case, they should be fed a little forward and slightly rotated to unhook the prong from the fabric, and only then removed.

4. Hot baths are recommended. First, you should apply a pressure bandage above the wound and lower the pricked limb for 30-60 minutes in hot water, the temperature of which is slightly below the burn threshold. 3% magnesium sulfate can be added to the water. Every 10 minutes, the pressure bandage should be loosened and tightened again.

5. Finally, apply an antiseptic dressing and immobilize the limb.

Interesting Stingray Facts

• On the coast of North America, about 750 people suffer from stingrays every year.
• Death is recorded in 1% of cases of contact with stingrays.
• Contact with a stingray proved fatal to popular Australian naturalist and broadcaster Steve Irwin.
• Indians, Malays, Aborigines of Australia and the inhabitants of the islands of the Pacific and Indian Oceans used stingray spikes as points for their spears and arrows. And since a stingray can grow a new thorn several times in its life, the natives even cultivated stingrays.
• Pliny the Elder in his “Natural History” compared the spike of a stingray with a formidable weapon that can kill a tree and pierce armor.

Consequences of a venomous stingray sting

Southern stingray spines (Dasyatis americana)

Rays form one of the largest and most important groups of venomous marine animals. 2,000 stingray stings are reported annually in the US. They live in warm, subtropical and tropical waters. The favorite habitat of these passive, secretive animals is the sandy or muddy bottom of closed lagoons and estuaries, where they feed on crustaceans and molluscs.

Rays have one to four venomous stings on the back of an elongated whip-like appendage. This tail is a cartilaginous process studded with serrated spines. It is covered with a thin layer of skin that hides two ventrolateral areas with venom glands. When the tail plunges into the prey, the epithelial lining of the glands ruptures, releasing the venom. Like other venomous fish, the shell breaks on contact with prey, allowing the venom to enter the wound. The venom contains at least 10 amino acids and toxic substances, including phosphodiesterases, 5′-nucleotidase and serotonin. When extracted, the poison is very quickly destroyed, as it is very unstable and thermolabile.

Rays only attack defensively, and this usually happens when humans inadvertently touch or step on an animal. If you touch the wings of a stingray, then it throws its tail forward, plunging it into the victim. Out of the water, a stingray can also prick a person while in a net or on a hook. There has been a documented case of injury by a person stepping on a dead, decaying animal.

Rays occasionally appear on the coast of Wales. Below is a case of a fisherman getting a lacerated wound on his lower leg from contact with a stingray.

Case description
Stingrays appeared on the coast of Wales in July 1994. An angler caught a 19 kilogram (42 lb) stingray in south Wales but was able to avoid contact with the venomous stinger. On the west coast of Wales, a fisherman caught an 18-kilogram (40 lb) stingray during a fishing event run by the Welsh Fire Department. Several colleagues helped him get the animal to shore, and, unfortunately, one of them hit the stingray, which stuck its tail into the fisherman. The sting penetrated boots (modified rubber) and trousers, tearing the shin of the left leg. The patient reported acute pain in the area of ​​the wound. Later the pain spread to the ankle. The fisherman went to the nearest emergency room. The doctor who examined him reported the incident to the Welsh National Poisons Unit, who gave advice on how to treat the injury. The wound was washed with warm water to neutralize thermolabile poisons. Then it was disinfected, and the edges of the wound were treated surgically under general anesthesia. The wound was not sutured, but bandaged, and the patient was left overnight for further observation. The patient was prescribed antibiotics, tetanus toxoid vaccine was not required. The angler was discharged the next morning and was seen by his therapist. Follow-up showed that the patient went to the emergency room again because the leg was swollen and red. The soft tissues of the leg were examined several times, and the wound healed in two months. There was an 8 cm scar on the lower leg.

Discussion
Clinical manifestation
The symptoms of the injection appear immediately. Severe pain appears in the area of ​​the wound, proportional to the severity of the injury. Swelling around the wound is constant, but its severity may vary. The wound turns blue, then erythema (violent reddening of the skin caused by capillary dilation) and petechiae (tiny hemorrhages) may appear. As a result, local tissue necrosis, ulceration, gangrene may occur. Pain peaks within 90 minutes. Without medical treatment of the wound, the pain lasts up to 48 hours. Systemic manifestations and signs can vary greatly and include nausea and vomiting, muscle cramps and fasciculations, sweating, fainting, and headaches. Cardiac arrhythmias, hypotension, convulsions and, in rare cases, death have also been reported.

Soft tissue injury from a stingray sting can be quite extensive. In addition to the stab wound, the cutting action of the spikes leads to damage and rupture of the underlying soft tissues. Most often, people injure the lower and upper limbs. Serious injuries and deaths from stings from rays are described in Cooper’s article, including fatal cases from tail strikes to the chest and abdomen. Foreign components (cartilage and epithelium) can get into the wound. Secondary infection is quite common due to the unique environment created by seawater. Pathogenic marine bacteria can be halophilic (bacteria that live in environments with high salt concentrations), heterotrophic (bacteria that need complex compounds for nutrition, since the possibilities for their synthesis are limited), motile, gram-negative. The genus of bacteria Vibrio (Vibrio) is quite common and can be very dangerous for people with weakened immune systems.

Treatment
The goal of treatment is to neutralize the local and systemic effects of the poison, reduce pain and prevent infection. The wound should be treated immediately with any available liquid. In practice, as a rule, this is sea water. Any noticeable pieces of stinger or epithelial tissue should be removed. As soon as possible, the wound should be washed with warm water (about 40 ° C) for 30-90 minutes, avoiding possible thermal damage. Heat will inactivate any thermolabile poisons. If the pain persists, it can be relieved by lavage with warm water, regional anesthesia, or wound infiltration. Vesicular fluid should be removed in a timely manner under sterile conditions. Then the wound is washed again, examined, necrotic tissues and foreign bodies are removed. With the help of X-rays, the remains of radiopaque cartilage spikes can be determined.