Combat Arts Forearm Injuries Overview
UFC fighterTony “El Cucuy” Ferguson is widely regarded as one of thebest lightweights in the history of the UFC.
Ferguson is reported to have fractured his left ulna in a 2012 UFC bout against Michael Johnson, and to have come back and fought many times since. Accounts like this come from media reports rather than medical records, so treat the details loosely. What they do show is the useful part: a forearm fracture, treated properly, does not have to end a career.
Forearm Injury Causes
Martial arts and combat sports utilize the arm for defensive moves such as blocking strikes and kicks, throws, offensive moves such as armbars, grappling, hammer blows and punches, so it’s no surprise that the arm is the most commonly injured body part in fighters.
Forearm fractures and injuries are common in mixed martial arts. The natural reflex of defense is to use the forearm. In many combat sports, the forearm is used for grip. And grip strength is used to control a wrist or holding a submission. Grip strength can win or lose a fight. While using the forearm to block a forceful kick, the bony part is exposed. The bony part tends to be the ulna. In most forearm injuries, it’s this ulna that is injured.
Forearm Injury Symptoms
Types of Forearm Injuries
There are various fractures involving the bones in the forearm. A Galeazzi fracture is a break of the radius, usually the middle to distal third, together with disruption of the distal radioulnar joint at the wrist. A Monteggia fracture is a break of the proximal ulna with dislocation of the radial head at the elbow. And then there’s the nightstick fracture, the one most often seen in mixed martial arts, where the ulna is broken on its own.
Arm Injuries Due to Hand to Hand Combat Training Are Common
Learn When to Get Help Versus Training Through the Pain
Related Injuries
This occurs when the bones of the forearm have been heavily impacted resulting in the hairline or non-displaced fractures, or comminution fractures either with or without multiple fragments. This injury is sometimes called the “nightstick” injury since it traditionally resulted from protecting oneself from attackers using a club, heavy bar, or nightstick.
Symptoms
The symptoms will be obvious as there will be extreme pain after a training accident, attack, or fight event. Symptoms may include:
Causes
Forearm fractures in martial arts combat events most often occur when a fighter is using the arm to block a kick to the head or shoulder resulting in a bone fracture to the outer forearm.
To learn how Nightstick Fracture is diagnosed, Click Here
Galeazzi fractures are uncommon. They are usually reported as roughly 3 to 7% of forearm fractures — not a share of every adult fracture. This is a forearm fracture seen in other sports like football and wrestling too. It is a fracture of the middle to distal one-third of the radius, and it is often associated with either dislocation or subluxation of the distal radioulnar joint.
Symptoms
Causes
The radius and ulna in the forearm are stabilized by three ligaments. The interosseous membrane disperses the axial load to the forearm. This distribution is about 60% to the radiocapitellar joint and 40% to the ulnohumeral joint.
When a fighter falls on an outstretched hand with an extended wrist and a hyperpronated forearm, the load is displaced. The energy from the radial fracture is transmitted down the interosseous membrane to the distal radioulnar joint at the wrist, which is the joint that ends up disrupted. In MMA, falls on an outstretched arm are not as common as in other sports, but accidental injuries can cause Galeazzi fractures.
To learn how Galeazzi Fracture is diagnosed, Click here.
In a Monteggia fracture, the proximal ulna is fractured along with a dislocation of the radial head at the elbow. They are commonly seen in athletes who sustain falls or receive a direct blow to the forearm. This usually occurs while the elbow is extended and the forearm is hyperpronated.
The fracture is caused when the energy from the ulnar fracture is transmitted along the interosseous membrane. It causes the proximal quadrate and annular ligaments to rupture. This disrupts the radiocapitellar joint. These are not as common with them accounting for about 1% of all forearm fractures.
The Monteggia fractures are classified into four categories
To Learn How Monteggia Fracture are Diagnosed, Click Here
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Common Forearm Injuries
For common forearm injuries like sprains and strains, refer to our Common Injuries section.
Forearm Injury Diagnosis
Forearm fractures are complex fractures. The Monteggia fracture is the most difficult to diagnose. If forearm fractures are missed, the morbidity is very high — permanent disability, limited motion, and chronic pain. Nerve injury can come from the original trauma, and occasionally from forceful attempts to straighten the bones, which is one more reason to leave reduction to a clinician instead of a cornerman.
Galeazzi fracture typically also have a high rate of morbidity. They are easily missed on radiographs. Muscle entrapment may also complicate the diagnosis. It is imperative that when forearm fractures are suspected images are done right away.
MMA fighter Ryan Jimmo was reported to have kept fighting with a broken forearm, telling officials he could feel the bone moving before anyone took him seriously. That is a media account rather than a case report, but the lesson stands: not all fractures break the skin, so a closed fracture is easy to dismiss, and pain that severe in a bout needs to be checked, not argued about.
Injury Specific Diagnosis
Physical Exam
On physical examination, a thorough examination of the skin is done to rule out any open fractures. These require immediate surgical care. Next, a thorough examination of the elbow and wrist is done. This is to rule out any associated Monteggia fracture or other wrist injuries. Doctors will test the range of motion at the elbow. They will palpate the area for any "clicks" or "clunks." This is done in particular at the site of the radial head. They will also do a "shuck test" at the wrist. This is just to check for weakness or instability of the distal radioulnar joint (DRUJ).
Imaging
X-ray films are the most important test. X-rays of the elbow, including a lateral view, are done to check the alignment of the radial head; any misalignment raises suspicion of a Monteggia fracture. X-rays of both wrists are done to assess the wrist joint, with films taken in pronation and supination for comparison. Plain films are usually enough — CT or MRI is added only when the picture is still unclear or another diagnosis has to be ruled out.
Lab Tests
Polytrauma fighters and those scheduled to undergo surgeries will require tests. These include blood tests, chest Xray and an ECG. Blood tests will include hemoglobin, BUN/Creatinine, Glucose, PT, PTT, SGOT, ALK, CMP, and others. In females, a pregnancy test will also be required.
To learn how Nightstick Fracture is treated, Click Here
Physical Exam
On physical exam, the orthopedic doctor visually inspects the skin and soft tissue. They will look for visible bony deformities, lacerations on the skin where the bone might protrude, muscle contusions, damage to the and neurovascular deficits. The open fractures will necessitate immediate surgical intervention without a further physical exam.
They will gently palpate the bone to identify deformities and point tenderness. The stability of the proximal and distal joints is assessed. This will help to identify any simultaneous injuries. A detailed neurovascular exam is performed to look for signs of acute compartment syndrome. They will examine the median and radial nerve distribution to see if there is any nerve damage.
Imaging
X-ray films are warranted. Usually, an anteroposterior and lateral view is used to identify the fracture. An oblique view is ordered to classify the injury. Classifying the injury will influence the treatment. X-ray films are obtained from the distal wrist and proximal. This is to rule out any concomitant injury. On Xray imaging, signs of disruption of the distal radioulnar joint (DRUJ) are seen as widened DRUJ, an ulnar styloid fracture, dorsally displaced ulna on the lateral view, and shortening of radius more than greater than 5 mm. In all cases of forearm fractures, Xray films of the normal limb are taken for comparison. Usually, Xray films are enough. If fractures involve non-union, then, a CT scan and magnetic resonance imaging (MRI) can help evaluate for ligament tears and disruption.
Lab Tests
If surgical treatment is required, then it will need blood tests and an ECG. Blood tests will include hemoglobin, BUN/Creatinine, Glucose, PT, PTT, SGOT, ALK Phos. In females, a pregnancy test will also be required.
To Learn how Galeazzi Fracture is treaded, Click Here
Doctors will visually inspect the skin and soft tissue for visible bony deformities, contusions of the muscles, skin lacerations, damage to ligaments and tendons and neurovascular deficits. They will palpate the bones and identify tenderness along the injured bone. They will examine both, the proximal and distal joint. This is to rule out any coexisting injuries. They will look for signs of acute compartment syndrome and radiating pain. The examination of the radial and median nerves is important for identifying nerve damage.
Xray films are essential for all forearm fractures. To identify the fracture, an anteroposterior and lateral view is done, and an oblique view can classify the injury. X-ray films of the distal wrist and proximal elbow are also done. Plain films are usually enough; CT or MRI is added when tears or disruption in the stabilizing ligaments need assessing.
Pre-operative tests include blood tests, chest Xray and an ECG. Blood tests will include hemoglobin, BUN/Creatinine, Glucose, PT, PTT, SGOT, ALK, CMP, and others. In females, a pregnancy test will also be required.
To learn how Monteggia Fracture are treated, Click Here
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Diagnoses of Common Forearm Injuries
The Common Diagnoses section will discuss the X-rays and other radiological modalities to diagnose skeletal fractures.
Forearm Injury Treatment
The treatment of forearm fractures depends on the type of fracture and the joints involved. Fighters who suspect a forearm fracture must see an orthopedic doctor. The length of treatment depends on multiple factors, including the severity of the injury, age, the type of fracture, and what the arm has to do afterwards. Bone healing does not run on a fixed clock: a straightforward forearm fracture is commonly immobilized for 6 to 8 weeks, and the bone goes on remodeling for months after that.
If surgery is warranted, rehabilitation usually starts early rather than late — often within the first couple of weeks after the operation — on a schedule set by your surgeon. The goal of any post-surgical rehab is to help athletes regain a full range of motion and fine motor skills. A good sign of healing is pain settling and motion coming back. Fighters returning to high-demand activity commonly need 12-16 weeks of rehabilitation care. Surgical hardware like screws, pins, and plates is often left in place, but it can be removed if it causes problems — that call is made with the surgeon.
Injury Specific Treatment
Emergency Treatment
Most nightstick fractures are closed. Splint the forearm as you find it, ice over the splint, keep it supported, and get seen the same day by a doctor. If bone is through the skin, or the skin over the fracture is broken at all, treat it as an open fracture and go straight to the emergency department. Cover the wound with a clean dry dressing, do not push anything back in, do not wash it out yourself, and do not eat or drink in case surgery is needed. Open fractures need urgent surgical washout, antibiotics and a tetanus check. Leave pain medication to the medical team.
Medical Treatment
Non-displaced fractures may be treated with a long-arm cast. A long arm cast is used to completely immobilize the fracture and allow healing. The cast usually remains for 6-8 weeks at which time a removable fracture brace may be used until completely healed. Displaced and/or comminuted fractures usually require surgery to insert a metal plate. This surgery usually allows the new solid bone to grow in the gap. This plate may or may not be removed once healing is achieved. Fighters will often decide to leave the plate in place as it gives more strength to the area, and removal means more downtime before resuming fighting.
Home Treatment
For isolated nightstick fractures, early mobilization generally helps recovery. Rather than long rigid immobilization, doctors often move to a functional brace, and a below-elbow brace is usually preferred to an above-elbow one. Displaced or unstable fractures are a different story and may be casted or fixed surgically first. Follow the plan your own doctor sets, because it depends on how the bone sits on the X-ray.
Emergency Treatment
These fractures need an orthopedic consult. Rest, ice, immobilization and elevation are the first steps for a suspected fracture, with the forearm supported in a sugar tong splint, and the fighter should be seen the same day. If the skin is broken over the fracture, go straight to the emergency department — that is an open fracture. In adults, Galeazzi fractures nearly always end up needing surgery.
Medical Treatment
Surgery is usually preferred, since closed reduction in adults tends to have a poor prognosis. First, the radial shaft fracture is fixed with rigid fixation. Then the stability of the DRUJ is tested during the operation. If the joint is stable once the radius is fixed, nothing further is needed there. If it is unstable, the joint is reduced and held — commonly with K-wires — and a torn ligament is repaired. If there is an accompanying ulnar styloid fracture, the ligament is repaired and the styloid is fixed with a lag screw or tension band wire.
Home Treatment
At home, rest is advised, with the forearm cast in supination in an elbow splint. Watch for wound infection: spreading redness, discharge, or fever. Watch harder for compartment syndrome, which is the one that costs you an arm. The warning signs are pain far out of proportion to the injury, severe pain when someone gently straightens your fingers, a forearm that feels tight and swollen, and numbness or tingling; weakness comes later. That is a surgical emergency — go to an emergency department immediately, keep the arm at heart level rather than propped up high, and never sit on it in a tight cast, splint or wrap. A tight cast must be split or loosened, not tolerated.
All Monteggia fractures are considered highly unstable and will require surgical intervention. Immediate, orthopedic consult is warranted. Rest, ice, immobilization, and elevation are the first steps after a fracture is suspected. Fighters must place their forearms in a sugar-tong splint and advised urgent referral to an orthopedic doctor.
Despite the closed reduction, Monteggia fractures in adults are more prone to angulation and shortening. Therefore, these fractures are fixed by a procedure called open reduction internal fixation (ORIF). A compression plate is fixed with six cortical screws proximally and distally. Once the plate is in place, the radial head dislocation is easily reduced.
After surgery, the splints and angles of casting all depend on the type of fracture. The forearm is placed in a long-arm splint. It is fully supinated with elbow flexion around 100-degrees for Types 1, 3, and 4 fractures. In the case of type 2 fractures, the elbow is splinted at 70-degrees. Pain medications are started and rehab begins 2 weeks after surgery. Despite this, fighters still complain of chronic pain and limited motion.
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