Hand and Wrist Injuries in Mixed Martial Arts: A Guide to Diagnosis and Treatment

Abstract

The sport of mixed martial arts is a blend of many martial arts resulting in a combination of striking and grappling in a fighting contest. A clear set of rules direct the sport’s action. Techniques include strikes with the extremities, throws and takedowns, as well as joint manipulation and chokes. Its popularity is rapidly growing worldwide. Just as with any combat sport, injuries are inevitable. However, research into the sport is still in its infancy. Given its surging popularity, surgeons who treat the hand and wrist should have an understanding of the sport, its potential causes of injury, and the current research that exists.

Full text

63
© Springer International Publishing AG, part of Springer Nature 2018
R. Luchetti et al. (eds.), Hand and Wrist Injuries In Combat Sports,
https://doi.org/10.1007/978-3-319-52902-8_7
Hand andWrist Injuries inMixed
Martial Arts
M.LuciusPomerantz
7.1 Introduction
The sport that we call mixed martial arts (MMA)
is different from other more “traditional” martial
arts in that it employs striking and grappling
techniques from multiple disciplines. It is related
to other “no-holds-barred” ghting disciplines
such as pankration, which dates to Greek antiq-
uity [1]. While MMA is not unique in combining
many forms of combat, it is unique in its recent
development and evolution to sport. It was not
until 1993 when what we consider modern day
MMA began to take form. In that year the
Ultimate Fighting Championship (UFC) was
started with the intention of placing competitors
of different martial arts against each other to see
which art was the most effective in combat. It
was a “no-holds-barred” event meaning that min-
imal rules governed what techniques could be
used against one another. It was overtly violent
and, comprised of many size and skill mis-
matches. Many found it distasteful. The public
backlash resulted in the sport being banned in
many states within the United States of America
(USA). However, in the late 1990s and early 2000s,
an effort was made to increase the safety of the
sport and make it more spectator-friendly. Since
that time, the sport has evolved greatly and experi-
enced a surge in popularity making it one of the
fastest growing sports in the world [2]. It was
reported in 2012 [3] that 5.5 million teenagers
and another 3.2 million children participate in
MMA in the USA, which is comparable to other
more traditional sports such as baseball and
American football. The UFC recently sold for
over $4billion reecting its worldwide presence
and popularity [4]. As the sport has evolved, what
used to be a contest of one martial art versus
another has become a combination of those arts
and a new sport in itself.
Given the popularity of the sport, it is impor-
tant for physicians and surgeons to be able to
understand and anticipate the injuries that ath-
letes may sustain during their participation.
Given the overlap of MMA with boxing, wres-
tling, Brazilian Jiu Jitsu, judo, Muay Thai kick-
boxing, and other martial arts (see Table 7.1),
there is also an overlap in the occurrence of inju-
ries. However, MMA is its own sport that does
require its own analysis. This article will empha-
size the rules, techniques, and equipment that
may contribute to injuries of the hand and wrist
as well as a review of the current available litera-
ture. As a former competitor in MMA and a
fellowship- trained hand surgeon, I have a unique
perspective and access to the sport.
M. L. Pomerantz
Orthopedic Surgeon, Upper Extremity/Hand
Subspecialization, Synergy Specialists Medical
Group, San Diego, CA, USA
7

64
Table 7.1 General comparison between various martial arts
Martial art
Strikes
with
the
hand
(sts)
Strikes
with
elbows
or
forearm
Strikes
with
knees
Strikes
with kicks
(including
shin or
foot) Biting
Strikes
with
the
head
Throws or
takedowns
Fighting
on the
ground Submissions Chokes
(Generalized)
targeted areas Fight area
Gloves/
weight of
gloves
Apparel (based on
highest
competition level)
% with
hand/wrist
injury (if
available)
JudoaNo No No No No No YesbYes Yes Yes Extremities
or neck
Mats with
dened
out of
bounds
without
barrier
No Gi with belt 6–30
[5–7]
WrestlingcNo No No No No No YesbYes No No Extremities
or neck
Mats with
dened
out of
bounds
without
barrier
No Singlet and
specic foot wear
3.5–11.0
[6, 8–10]
Brazilian
Jiu Jitsud
No No No No No No Yes YesbYe s Yes Extremities
or neck
Mats with
dened
out of
bounds
without
barrier
No Gi with belt or low
prole clothing for
no Gi contests
11.1 [11]
Samboe,f No No No No No No Yes Yes Ye s Yes Extremities
or neck
Mats with
dened
out of
bounds
without
barrier
Dependent
on venue/
4–6oz
Gi top, shorts,
headgear, mouth
guard, groin
protection, open
ngered gloves,
leg pads covering
the front part of the
shin and lacing of
specic foot wear
NA
KarategYes No No Ye s No No Ye s No No No Head and
trunk
Mats with
dened
out of
bounds
without
barrier
Dependent
on
venue/4–
10oz
Kimono with belt,
body protection,
karate mitts, foot
pads, shin pads,
mouth guard, with
or without groin
protection
3.0–12.5
[12–14]
M. L. Pomerantz

65
BoxinghYesbNo No No No No No No No No Head and
trunk
Enclosed
area
within
ropes
Yes/8–
10oz. for
competition
up to 16oz.
for training
Shorts, specic
foot wear, groin
protection, mouth
guard, hand wraps
with or without
headgear
6.5–17 [6,
15–17]
Muay ThaiiYes Yes Yes Yes No No Yes No No No Few
restrictions
Enclosed
area
within
ropes
Yes/8–
10oz. for
competition
up to 16oz.
for training
Boxing gloves,
hand wraps, shorts,
groin protection
2.3–2.9
[18, 19]
TaekwondojYes No No YesbNo No No No No No Head and
trunk
Octagonal
mats with
dened
out of
bounds
without
barrier but
on
platform
Dependent
on venue
(becoming
more
common)
/4oz
Dobok with trunk
protector,
headgear,
mouthpiece, groin
area protector,
gloves, and shin
and forearm guards
8–10.8 [7,
20, 21]
MMAkYes Yes Yes Yes No No Yes Yes Yes Yes Few
restrictions
Enclosed
area
within
ropes or
cage
Yes/4–6oz Gloves, hand
wraps, mouthpiece,
shorts, groin
protection
5–17.7
[22–28]
ahttp://www.nbcolympics.com/news/judo-101-rules-scoring#scoring
bPrimary attack (perhaps numerical classication in a seperate location)
chttp://www.nbcolympics.com/news/wrestling-101-rules
dhttps://www.usgrappling.com/rules/
eSome variations of rules allow striking (perhaps numerical classication in a seperate location)
fhttp://samboas.org/uploads/documents/FIAS/FIAS_Sambo_Rules_2015_EN.pdf
ghttp://www.wkf.net/pdf/wkf-competition-rules-version9-2015-en.pdf
hhttp://www.teamusa.org/usa-boxing/rulebook/competition-rules
ihttp://www.ikfkickboxing.com/RulesMT.htm
jhttp://www.worldtaekwondofederation.net/rules/
khttp://www.ufc.com/discover/sport/rules-and-regulations
7 Hand andWrist Injuries inMixed Martial Ar ts

66
7.2 Mixed Martial Arts
To understand MMA, one should have a brief
understanding of the terminology involved.
Martial arts are the practice of combat and self-
defense and have likely existed for as long as
civilization [1, 29]. There are many different
types of martial arts with different cultural inu-
ences and emphases, but all have the objective of
engaging an opponent in direct combat. Often,
they become sporting contests with rules that dic-
tate the objectives of the contest and increase
safety. For MMA, what used to be a contest to see
which martial art is superior has morphed into a
combination of the martial arts, hence the name
mixed martial arts.
There are countless techniques that one can
use against another person to gain superiority in
combat, but they can be organized into general
categories. “Striking” is when a person uses their
extremities to strike their opponent and requires
some distance, also known as range, between the
combatants. Strikes in MMA most often involve
the hands in the form of a closed st but, for
example, can also be with an open hand (ngers
extended), elbows, knees, shins, or the feet.
“Grappling” involves closer range combat that
requires grasping of the opponent. Grappling
often involves bringing the engagement to the
ground via a throw or “takedown.” Other attacks
include joint manipulation such as hyperexten-
sion or twisting and have been termed “submis-
sions.” To successfully use a “submission,”
torque on the joint is created by applying force
through moment arms proximally and distally to
the joint. An example of this would be by per-
forming an “arm bar,” which creates hyperexten-
sion at the elbow by directing force on the
humerus in one direction and then applying an
opposite force through the forearm (Fig. 7.1).
Chokes are attacks where the ability to breath
and/or blood supply to the brain is temporarily cut
off. The opponent can concede, or “submit”, to
their opponent before injury, or unconsciousness
occurs via signal. Often the signal will be tapping
their hand repeatedly onto their opponent or “tap-
ping out,” but the signal can also be verbal.
7.3 Rules inMMA
Unied Rules and Regulations of Mixed Martial
Arts exist [30] and contributed to the growing
acceptance of the sport. I intend to summarize the
rules in a way that applies to the goals of this
paper. For a full list of rules and regulations, see
reference. A general comparison of martial arts
can be seen in Table 7.1 including legal tech-
niques, ghting area, and apparel.
The Fighting Area: The contest usually takes
place on a at surface with foam padding and
lined with canvas or similar material to prevent
Fig. 7.1 Arm bar
M. L. Pomerantz

67
slipping if wet. It may be bordered by a chain link
fence or “cage” of various shapes or may be simi-
lar to a boxing ring lined with ropes. The most
famous example is in the UFC, which trade-
marked an eight-sided cage or “the Octagon.” It is
illegal to intentionally grasp the cage or fence
although leaning into or pushing off of it or push-
ing one’s opponent against it are common tactics.
Potential Injuries: The ghting area itself is a
rare source of reported injuries as grasping the
cage or fence is illegal; however, it is a possibility
that a digit may become caught within the cage or
the junction with the oor, resulting in a twisting
or avulsion type of injury. In a small survey [22],
12% of respondents did report an injury as a
result of the cage.
Fighting Apparel: Include groin protection,
shorts or similar lower extremity clothing, mouth
guard, hand wraps, and gloves. The gloves are
usually 4oz. (113g) but can be 6oz. (170g) for
larger-sized ghters. The gloves have open, inde-
pendent ngers with padding extending over the
metacarpophalangeal (MCP) joints and the prox-
imal phalanges but end at the proximal interpha-
langeal (PIP) joints (Fig. 7.2). In comparison,
modern competition boxing gloves weigh
8–10oz. (227–284g) and completely enclose the
ngers and thumb, which cannot be separated
from the st (Fig.7.2). Lastly, but importantly, it
is illegal to grasp the apparel.
Potential injuries: Gloves for combat sports
are utilized primarily to protect ones hands [29,
31, 32] and not necessarily the opponent being
struck. Closed-sted punching is more utilized in
striking arts when gloves are allowed as they
reduce the risk of injury to the person throwing
the punch [29]. In MMA, since the ngers of the
gloves are independent, they are subject to forces
not seen in boxing such as twisting, hyperexten-
sion, and similar type of injuries. With the gloves
ending at the proximal phalanx, the PIP joint
likely sees increased forces. An example of an
injury is seen in the publicly available photo of
UFC ghter Josh Emmett with an open ring n-
ger dorsal PIP joint dislocation (Fig.7.3). Also,
the thumb, in its lateral position on the hand, can
be snagged or impacted while throwing punches
that is not possible with modern boxing gloves
(see representation in Fig. 7.4). Older boxing
gloves had an independent thumb, and Noble
[31] noted in a study in 1987 that 39% of boxer’s
injuries were to the thumb and the majority
Fig. 7.2 Mixed martial arts gloves/boxing gloves. Standard MMA glove with open ngers compared to 16oz. training/
sparring boxing glove
7 Hand andWrist Injuries inMixed Martial Ar ts

68
(23/39 injuries) of these were ruptures of the
MCP joint ulnar collateral ligament (UCL).
Additionally, the smaller gloves in MMA com-
pared to boxing impart similar force to a smaller
area resulting in higher peak forces [33, 34] with
potentially increased injury to the hand compared
to larger gloves.
Since grasping clothing is not legal, the risk
of some injuries is reduced. When ngers can be
caught in clothing, shear and twisting injuries to
the ngers such as exor digitorum profundus
(FDP) avulsion injuries also known as “jersey
ngers,” pulley injuries, and other sprains can
occur. Sports where gripping clothing is very
common, such as judo [5] and Brazilian jiujitsu
[11] are noted to have these types of injuries. In
the survey [22] of MMA ghters, only 2% of
injuries were directly blamed on the apparel
worn such as getting the ngers snagged within
the shorts of their opponent.
Rules of Engagement: Specic rules in place
for overall ghter safety also contribute possible
hand injuries in MMA. Some injuries are less
likely due to the illegality of grasping the cage or
the opponent’s clothing as previously discussed
but also because nger joint manipulation is ille-
gal. Other rules that contribute to a unique injury
prole for MMA include the legality of kicks, but
illegality of striking the back of the head or neck
as well as kicking or kneeing the head of a
downed opponent. These will be discussed in fur-
ther detail in the coming paragraphs.
A rule that fortunately prevents many injuries
to the hand and ngers is that intentional nger
joint manipulation is not allowed. This means
that a person may not grab an individual nger
and bend or twist it. Manipulation of the wrist
joint is legal but is less commonly targeted com-
pared to other larger joints. It is difcult to isolate
the wrist joint and keeping it trapped compared to
larger joints, which have longer moment arms
that are easier to grasp and manipulate.
Potential Injuries: As mentioned before, strik-
ing with a closed st is the most commonly
employed strike in MMA, and an injury prole
similar to other striking sports like boxing is
expected. However, there are several ways in
which MMA may allow for different hand inju-
ries compared to other striking arts beyond the
previously discussed gloves. First, there are
often situations when powerful kicks impact the
lightly padded defender’s hand or wrist poten-
tially causing injury, as may be seen in tae-
kwondo or karate. Also, given the grappling
component of MMA, there are many situations
where the back of the opponent’s head and neck
are exposed to strikes; however it is illegal to hit
these areas. To avoid executing an illegal strike,
one needs to angle or “loop” the punch toward
the legal target areas, creating impact on the
radial or ulnar hand as opposed to directly over
the MCP joints (Fig.7.5). Specically, the thumb
and second ray as well as the ulnar hand are
exposed to forces not usually seen in boxing or
Fig. 7.3 Josh Emmett open ring nger PIP dislocation
injury
Fig. 7.4 Example of independent thumb being deviated
away from the hand during a punch
M. L. Pomerantz

69
kickboxing but are seen in karate or taekwondo.
The decreased padding, independent ngers, and
unique forces on the hand will result in a unique
injury prole. A representative case is UFC ghter
Mark Hunt (a former champion kickboxer and
now competitor in MMA) who injured his hand
and placed photos available publicly on his social
media website (Figs.7.6a and 7.6b).
The ground-ghting component of the sport
also contributes to injury. For safety reasons, it is
not legal to kick or knee the head of an opponent
that has anything but their feet touching the
ground. Due to this ground-ghting constraint of
MMA, there are situations where the aggressor
must use his arms to strike the opponent instead
of the legs increasing the chances of injury to the
hand. Also, when trying to punch a moving oppo-
nent on the ground, it is possible to actually strike
the ground instead, which may result in injury.
7.4 Review ofLiterature
An English language literature search of
PubMed, Cochrane, and Google Scholar of
“Mixed Martial Arts Injuries” revealed 51 publi-
cations. Case reports and articles relating to top-
ics other than injuries to the extremities were
excluded. Review of abstracts allowed the search
to be narrowed to 11 publications. Review of
those articles left eight articles that addressed the
goal of assessing the rate of upper extremity
ab c
Fig. 7.5 Examples of looping punches to avoid illegal strike (a) uppercut from behind (b) indirect punch from behind
(c) hammer punch from top position
ab
Fig. 7.6 Mark Hunt’s fractured hand (source: Mark Hunt’s Facebook Page)
7 Hand andWrist Injuries inMixed Martial Ar ts

70
Table 7.2 Review of available articles discussing upper extremity injuries in Mixed Martial Arts
Paper Year Type of study
Source of
information
Number of
matches/
ghters
Average age/
gender
Number of injuries/
ghters injured
Number of
upper extremity
injuries (percent
of total injuries)
Types of injuries
(not specic to
upper extremity
injuries unless
specied)
Overall injury
rate
Bledsoe
etal. [28]
2006 Retrospective
cohort study
Nevada State Athletic
Commission
2001–2004
171/220 28.5years/100%
male
96/78 21 (21.9%) Specics not
detailed. Most
common injury was
facial laceration
(47.9% of injuries
or a rate of
13.45/100
competitors)
28.6 per 100
ght
participations
(0.286/exposure)
Hand: 13
(13.5%)
Shoulder: 5
(5.2%)
Hand injuries
13.5% or a rate
of 3.8/100
competitors
Elbow: 3 (3.1%)
Arm: 1 (1%)
Ngai etal.
[35]
2008 Retrospective
cohort study
Nevada State Athletic
Commission
2002–2007
635/1270 NA/100% male 356/300 67 (18.8%) “Upper limb
injuries”: occurred
in 6.5% decisions,
7.7% of TKO, 3.3%
of submissions, and
0% in draws, DQs,
Physician ended
ghts, KOs
23.6/100 ght
participations,
loser 2.4× more
likely to be
injured
Rainey [23] 2009 Retrospective
cross-sectional
study
Survey NA/55 NA/94.5% male 207 47 (22.7%) 16.2% Strains NA
Shoulder: 13
(6.2%)
Finger: 9 (4.3%) 14.9% Sprains
Elbow: 7 (3.4%) 10.1% Abrasions
Upper Arm: 6
(2.9%)
9.2% Joint Trauma
Hand: 6 (2.9%) 5.7% Fracture
Wrist: 4 (1.9%) 5.3% Lacerations
2.6% Dislocations
M. L. Pomerantz

71
Scoggin
etal. [26]
2010 Prospective
Cohort
Hawaiin MMA
competitions from
1999–2006
116/179 Not specied 55/49 8 (14.5%) 1 lateral sprain, 1
medial sprain, 1
subluxation and 1
olecranon bursitis
0.237 injuries
per exposure
Elbow: 4 (7.3%)
Metacarpal: 3
(5.5%)
1 fracture, 2 other
injuries
AC joint: 1
(1.8%)
Separation
Diesselhorst
etal. [32]
2013 Retrospective
Cohort
Survey of 758
participants of
martial arts regarding
upper extremity
injuries (38%
participating in
“multiple martial
arts” though included
MMA)
NA/758 44years, 81%
male
NA Hand/Wrist/
Fingers: 53%
injured
Sprains/Muscle
Strains: 47%
NA
Shoulder/Upper
Arm: 27%
Abrasions/Bruises:
26%
Forearm/Elbow:
19%
Fracture of upper
Extremity: 39%
Dislocation: 47%
Otten etal.
[25]
2015 Retrospective
Cohort
NSAC (UFC events
2007–2009) Divided
into Figher
Complaints and
Doctor Observations
152/304 NA/100% Male 170 ghter
complaints, 91
Physician
Observations/120
(based on counting
presented data)
Fighers
Complained of:
Doctors Noted: 39.7/100
competitors
29 (17.1%) Lacerations/Soft
tissue injuries: 58
(63.7%)
Hand and Wrist:
15 (8.8%)
Shoulder: 4 (4.4%)
Arm/Elbow: 7
(4.1%)
Hand: 3 (3.3%)
Shoulder: 7
(4.1%)
(continued)
7 Hand andWrist Injuries inMixed Martial Ar ts

72
Table 7.2 (continued)
Karpman
etal. [36]
2016 Consecutive
case series,
observational
cohort
MMA bouts in
Edmonton 2000–
2002 and 2005–2013
1181
ghters
NA/99% male 926/702 Only injury
specic to body
part was
fracture: Hand/
arm fractures:
29 (49.2% of
fractures
recorded)
Contusion: 663
(56.1%)
59.4% overall
injury rate
Concussion: 98
(8.3%)
2.5% of which
were hand/arm
fractures
Laceration: 95
(8.0%)
Fracture: 59 (5.0%)
Eye injury: 3
(0.3%)
Dislocation: 2
(0.2%)
Other: 6 (0.5%)
Ji [24] 2016 Retrospective
cohort
Survey of 470 MMA
athletes Seoul or
Gyeongnam
province, Korea
between 6/2015 and
11/2015
455
ghters
(15
surveys
excluded)
62.4% between
20 and
29years/96.3%
Male
860/455 Arm: 253
(30.4%)
Laceration: 321
(37.3%)
NA
Hand: 71 (8.5%) Concussion: 179
(20.8%)
Wrist: 65 (7.8%) Contusion: 142
(16.5%)
Shoulder: 37
(4.5)
Fracture: 53 (6.2%)
Forearm: 25
(3%)
Strain: 51 (6.0%)
Finger: 15
(1.8%)
Joint: Dysfunction:
45 (5.2%)
Elbow: 3 (0.4%) Sprain: 25 (2.9%)
Dislocation: 20
(2.3%)
Epistaxis: 15
(1.8%)
Other: 9 (1%)
Paper Year Type of study
Source of
information
Number of
matches/
ghters
Average age/
gender
Number of injuries/
ghters injured
Number of
upper extremity
injuries (percent
of total injuries)
Types of injuries
(not specic to
upper extremity
injuries unless
specied)
Overall injury
rate
M. L. Pomerantz

73
Pomerantz
[22]
2017 Retrospective
cohort (not
published)
Survey of 93
respondents
93 ghters 79.3% between
20 and
35years/90.3%
Male
215/93 Arm: 59
(27.4%)
Laceration: 5
(5.8%)
NA
Shoulder: 37
(49.3%)
Concussion: 25
(11.6%)
Elbow: 22
(29.3%)
Neck Strain: 24
(11.2%)
Hand: 6 (8.0%) Fracture: 9 (4.2%)
Finger: 6 (8.0%) Strain: 11 (5.1%)
Wrist: 2 (2.7%) Lost Tooth: 7
(3.3%)
Sprain: 57 (26.5%)
Other: 4 (1.9%)
7 Hand andWrist Injuries inMixed Martial Ar ts

74
injuries in MMA. An additional article was
found through references pertinent to the
research topic, and another article is pending;
submission by the author of this paper and its
data is included. Table7.2 summarizes the nd-
ings of these studies.
In the articles reviewed, three articles were
based on results from surveys of ghters. In those
studies, the percentage reporting injury to the
hand and wrist occurred at 9.2% [23], 17.6%
[24], and 17.7% [22]. In four observational/
record review studies, the rates are 5% [25], 5.5%
[26], 12.0% (Nevada State Athletic Commission
2001–2009 as reported by Lystad, et al. [27]),
and 13.5% [28]. Another study [32], only looking
at upper extremity injuries, noted that 53% of
martial artist survey respondents reported upper
extremity injuries were to the hand/wrist. Two
other studies were not more specic than “arm/
hand” [36] or “upper limb” [35], and therefore
rates of injury to the hand and wrist could not be
assessed in these articles.
Unfortunately, only one article mentions spe-
cic injuries to the wrist, hand, or nger in MMA:
three metacarpal injuries including one con-
rmed fracture [26].
Given the heterogeneity of the structure and
results of these studies, meta-analysis was not
possible.
7.5 Discussion
There is a paucity of published data on injuries in
MMA, with even less described for hand and
wrist injuries. The studies that exist are limited
level 4 studies. The available research shows
hand and wrist injury rates of 5–17.7% in
MMA.Hand and wrist injuries reported for other
martial arts are also limited but include 6.5–17%
[6, 15–17] for boxing, 2.1–2.9% [18, 19] for
Muay Thai kickboxing, 3.0–12.5% [12–14] in
karate, 8–10.8% in taekwondo [7, 20, 21], 3.5–
13.4% in wrestling [6, 8–10], 6–30% [5–7] in
judo, and 11.1% [11] in Brazilian (Jiu Jitsu).
From the limited research, it does not seem that
MMA has a higher predilection to hand or wrist
injury than other combat sports. This conclusion
is also corroborated in a recent review of litera-
ture for several martial arts [37].
As previously mentioned, the specic types of
injuries sustained in MMA are essentially without
description in the literature. There are case exam-
ples available to review, and we can make edu-
cated guesses on the types of injuries that may
occur based on other martial arts. All things con-
sidered, from a hand and wrist injury viewpoint,
the striking component of MMA is most similar
to karate or taekwondo. However, many MMA
ghters have trained in boxing or kickboxing and
may have habits and training methods conducive
to boxing or kickboxing. As opposed to boxing,
karate and taekwondo have a combination of
striking with hands and feet, with different angles
of of strikes being used and with small gloves. For
less experienced MMA competitors, especially
those with experience in boxing or kickboxing,
there may be an even higher risk of injury as they
have not adapted to the needs of MMA.Finger
joint sprains/dislocations in karate are common
including thumb MCP joint injuries [12, 38], and
one study [38] attributed it to open-hand strikes or
catching ngers within the uniform. The most
common fracture observed in karate was a frac-
ture of the neck of the second metacarpal [39], but
rst metacarpal base fractures were also noted. As
cited before, Noble [31] described many thumb
MCP joint UCL injuries in boxers when the
gloves had an independent thumb. Other injuries
he noted were various fractures about the thumb,
two scaphoid fractures, injuries to the carpometa-
carpal joints of the hand including dislocation,
metacarpal fractures, and several proximal pha-
lanx fractures [31]. Other boxing injuries
described include radiocarpal strains, dislocations
or tears of the extensor digitorum communis, and
extensor carpi radialis and brevis tears [31, 40].
MMA has additional possible injuries from
grappling like those that may be seen in judo,
wrestling, or Brazilian Jiu Jitsu. Unfortunately,
there is not much described research on the spe-
cic injuries in these sports either. Specic injuries
described for a single Brazilian jiujitsu tournament
[11] include distal interphalangeal joint sprain,
thumb sprain, PIP joint dislocation, and ring nger
metacarpal fracture. Many injuries to the ngers in
M. L. Pomerantz

75
judo are attributed to being thrown but also to grip-
ping the uniform [5, 41]. Most of these injuries
were sprains and strains or “soft” injuries [5]. FDP
avulsion injuries, mallet ngers, and various
sprains and strains in the hand have been described
in judo [5–7, 41], and a case report of a dorsal dis-
tal radioulnar joint dislocation exists [42].
Wrestling hand injuries include many sprains of
nger joints including the thumb MCP joint [6,
10], but fractures have been reported [8, 9].
Through this review, in addition to personal
experience and observation, it is clear that MMA
presents risk of injury to the hand and wrist. This
is by the nature of the sport as well as the gloves
the competitors wear. While grappling is a large
component of MMA, fractures as a result of
impact are more likely to occur in MMA as
opposed to isolated grappling sports like judo,
Brazilian jiujitsu, or wrestling. Unlike boxing or
kickboxing, the thumb is exposed during punch-
ing, which could result in injuries from direct
impact or from being deviated. Also, compared to
boxing or kickboxing, where punches are less
angled, the strikes in MMA are more similar to
arts like karate where strikes come from many dif-
ferent angles and impact the hand differently
(Fig. 7.5a–c). The angled punching required in
certain situations will focus energy more on the
radial or ulnar aspects of the st resulting in a dif-
ferent injury prole. The gloves themselves con-
tribute to injury as they have independent ngers
to help with grasping the opponent but also allow
for potential twisting and shearing of the ngers.
Additionally, with the gloves ending at the PIP
joints resulting in relative deceased range of
motion proximally, there are increased forces that
the PIP joints experience, which I feel increases
the likelihood of PIP dislocations. Multiple PIP
dislocations are documented on publicly available
photographs on the Internet. The small gloves
also result in increased forces to the hand during a
punch or while defending strikes, which can result
in increased exposure to injury of the hand and
wrist. Injuries from the ght area or uniform/
apparel other than the gloves appear to be a small
contributor to hand and wrist injuries in MMA.
The nature of researching this type of injury
prole will continue to be based on surveys which
are subject to recall biases by those surveyed,
record reviews which are limited in scope and
information, and direct observation which has its
own limitations in study size, observer biases, and
logistical issues such as follow-up. Future
research will need to focus on determining the
specic injuries and their causes. This will help in
the prevention of injuries including possible new
designs for the gloves and changes in ght area
construction. Additionally, it will help the medical
personnel who care for these athletes to better
anticipate injuries and treat them.
At this point, we as surgeons of the hand and
wrist can expect to see more patients involved in
the sport of MMA with injuries similar to other
ghting arts but with possibly different injury
patterns. Their treatment will also be similar, as
the goals will remain the same. These athletes
will be as motivated to return to sport as any other
athlete and can be expected to take the steps nec-
essary to assure optimal outcome.
References
1. Poliakoff MB. Combat sports in the ancient world:
competition, violence, and culture. New Haven: Yale
University Press; 1987.
2. Dann J. 2014. http://www.mirror.co.uk/sport/
other-sports/mma/11-things-you-really-need-
3277676.
3. Keown T.MMA’s future. ESPN: The Mag. 2012.
4. Ozanian M. 2016. http://www.forbes.com/sites/
mikeozanian/2016/10/24/forbes-fab-40-the-worlds-
most-valuable-sports-brands/–3845b75b1d36.
5. Pocecco E, Ruedl G, Stankovic N, Sterkowicz S,
Del Vecchio FB, Gutierrez-Garcia C, et al. Injuries
in judo: a systematic literature review includ-
ing suggestions for prevention. Br J Sports Med.
2013;47(18):1139–43.
6. Rettig AC.Epidemiology of hand and wrist injuries in
sports. Clin Sports Med. 1998;17(3):401–6.
7. Kim KS, Park KJ, Lee J, Kang BY.Injuries in national
Olympic level judo athletes: an epidemiological study.
Br J Sports Med. 2015;49(17):1144–50.
8. Yard EE, Collins CL, Dick RW, Comstock RD. An
epidemiologic comparison of high school and
college wrestling injuries. Am J Sports Med.
2008;36(1):57–64.
9. Pasque CB, Hewett TE. A prospective study of
high school wrestling injuries. Am J Sports Med.
2000;28(4):509–15.
10. Hewett TE, Pasque C, Heyl R, Wroble R.Wrestling
injuries. Med Sport Sci. 2005;48:152–78.
7 Hand andWrist Injuries inMixed Martial Ar ts

76
11. Scoggin JF 3rd, Brusovanik G, Izuka BH, Zandee
van Rilland E, Geling O, Tokumura S. Assessment
of injuries during Brazilian Jiu-Jitsu competition.
Orthop J Sports Med. 2014;2(2):2325967114522184.
12. McLatchie GR.Analysis of karate injuries sustained
in 295 contests. Injury. 1976;8(2):132–4.
13. Tuominen R.Injuries in national karate competitions
in Finland. Scand J Med Sci Sports. 1995;5(1):44–8.
14. Pieter W. Competition injuries in young karate ath-
letes. Br J Sports Med. 1998;32:88.
15. Bledsoe GH, Li G, Levy F.Injury risk in professional
boxing. South Med J. 2005;98(10):994–8.
16. Zazryn TR, Finch CF, McCrory P.A 16 year study of
injuries to professional boxers in the state of Victoria,
Australia. Br J Sports Med. 2003;37(4):321–4.
17. Zazryn TR, McCrory PR, Cameron PA. Injury rates
and risk factors in competitive professional boxing.
Clin J Sport Med. 2009;19(1):20–5.
18. Zazryn TR, Finch CF, McCrory P. A 16 year
study of injuries to professional kickboxers in
the state of Victoria, Australia. Br J Sports Med.
2003;37(5):448–51.
19. Gartland S, Malik MH, Lovell ME.Injury and injury
rates in Muay Thai kick boxing. Br J Sports Med.
2001;35(5):308–13.
20. Pieter W.Epidemiology of injury in Olympic sports.
Oxford: Wiley-Blackwell; 2009.
21. Lystad RP, Graham PL, Poulos RG.Exposure-adjusted
incidence rates and severity of competition injuries in
Australian amateur taekwondo athletes: a 2-year pro-
spective study. Br J Sports Med. 2013;47(7):441–6.
22. Pomerantz M.Injury prole in Mixed Martial Arts.
2017. Unpublished.
23. Rainey CE.Determining the prevalence and assessing
the severity of injuries in Mixed Martial Arts athletes.
N Am J Sports Phys Ther. 2009;4(4):190–9.
24. Ji M.Analysis of injury types for Mixed Martial Arts
athletes. J Phys Ther Sci. 2016;28(5):1544–6.
25. Otten MHC, Ghazarian N, Boura J.Ultimate ghting
championship injuries; a two-year retrospective ght
injury study. Osteopath Fam Phys. 2015:13–8.
26. Scoggin JF 3rd, Brusovanik G, Pi M, Izuka B, Pang P,
Tokumura S, etal. Assessment of injuries sustained in
Mixed Martial Arts competition. Am J Orthop (Belle
Mead NJ). 2010;39(5):247–51.
27. Lystad RP, Gregory K, Wilson J. The epidemiol-
ogy of injuries in Mixed Martial Arts: a systematic
review and meta-analysis. Orthop J Sports Med.
2014;2(1):2325967113518492.
28. Bledsoe GH, Hsu EB, Grabowski JG, Brill JD,
Li G. Incidence of injury in professional Mixed
Martial Arts competitions. J Sports Sci Med.
2006;5(CSSI):136–42.
29. Murray S. Boxing gloves of the ancient world. J
Combat Sport. 2010:1492–650.
30. http://www.ufc.com/discover/sport/rules-and-reg-
ulations. Unied Rules and Regulations of Mixed
Martial Arts.
31. Noble C.Hand injuries in boxing. Am J Sports Med.
1987;15(4):342–6.
32. Diesselhorst MM, Rayan GM, Pasque CB,
Peyton Holder R. Survey of upper extremity inju-
ries among martial arts participants. Hand Surg.
2013;18(02):151–7.
33. Lee B, McGill SM. Striking dynamics and kinetic
properties of boxing and MMA gloves. Revista de
Artes Marciales Asiáticas. 2014;9(2):106–15.
34. Schwartz ML, Hudson AR, Fernie GR, Hayashi
K, Coleclough AA. Biomechanical study of full-
contact karate contrasted with boxing. J Neurosurg.
1986;64(2):248–52.
35. Ngai KM, Levy F, Hsu EB.Injury trends in sanctioned
Mixed Martial Arts competition: a 5-year review from
2002 to 2007. Br J Sports Med. 2008;42(8):686–9.
36. Karpman S, Reid P, Phillips L, Qin Z, Gross
DP. Combative sports injuries: an Edmonton retro-
spective. Clin J Sport Med. 2016;26(4):332–4.
37. Drury BT, Lehman TP, Rayan G. Hand and wrist
injuries in boxing and the martial arts. Hand Clin.
2017;33(1):97–106.
38. Destombe C, Lejeune L, Guillodo Y, Roudaut A,
Jousse S, Devauchelle V, etal. Incidence and nature of
karate injuries. Joint Bone Spine. 2006;73(2):182–8.
39. McLatchie G.Karate and karate injuries. Br J Sports
Med. 1981;15(1):84–6.
40. Porter M, O’Brien M.Incidence and severity of inju-
ries resulting from amateur boxing in Ireland. Clin J
Sport Med. 1996;6(2):97–101.
41. Green CM, Petrou MJ, Fogarty-Hover MLS, Rolf
CG. Injuries among judokas during competition.
Scand J Med Sci Sports. 2007;17(3):205–10.
42. Russo MT, Maffulli N.Dorsal dislocation of the distal
end of the ulna in a judo player. Acta Orthop Belg.
1991;57(4):442–6.
M. L. Pomerantz