Forearm Fractures in MMA- The New Nightstick Fracture

by Steve Mora, MD
Orange County Orthopedic Surgeon

Forearm fractures in mixed martial arts (MMA) are common. They usually occur when a fighter uses their arm to block a kick. Traditionally these injuries were called “night stick” fractures. The classic “night stick” fracture resulted from a direct blow to the forearm which occurred while defending oneself from an attacker wielding a stick or a club.  Over the last few years the majority of the fractures I see have occurred in MMA fighters.  The injury occurs when the arm is used to block a forceful kick.  The kick strikes the bony part of the forearm leading to the broken bone.

Blocking a kick with outer forearm exposes the ulna to injury
Blocking a forceful kick with a single arm exposes the outer forearm to injury.

When these fractures occur they can be non displaced (hair-line fractures) or displaced with or without multiple fragments (comminution).

comminuted ulna fracture
Comminuted ulna fracture

Treatment:  Non displaced fractures can sometimes be treated with a long arm cast.  A long arm cast rather than a short arm cast is used to maximally immobilize the fracture and therefore promote healing.  The cast is usually continued for 6-8 weeks and then removed.  After the long arm cast is removed a removable fracture brace may be applied until the fracture is completely healed. In some cases casting fails therefore surgery will need to be considered.

Fractures that are displaced and/or comminuted are typically treated with surgery. An incision is made centered over the fracture,  the fracture ends are brought together and a metal plate with screws is used to bridge the gap and secure the two fragments firmly together.  Typically surgical treatment leads to new solid bone forming in the gap.  Healing occurs over the course of 2-3 months.

Ulna shaft fracture in cast.
Typical ulna shaft fracture of forearm. This fracture was treated with a long arm cast.

When the fracture does not heal it is called a non-union.   A non-union means that the fracture gap did not form new bone therefore the fractured ends are not united or healed.  Non-unions cause instability (movement at the fracture site) and pain.

Ulna fracture non union after plating
Ulna shaft fracture which did not heal (non-union) despite being treated with plate fixation. This fracture fixation was revised with a stiff, locking plate and bone grafting.

Why do non-unions occur? There are numerous reasons why fractures do not heal.  Some of the reasons include abnormal blood flow due to smoking or disease such as diabetes, inadequate plate fixation (the plate was not sufficiently rigid), the fracture had multiple fragments (comminution), the patient was allowed to move too soon, or the surgical technique disrupted the soft tissue and impaired the healing process.

Does surgery always lead to healing? Not always. Despite being treated with surgery some fractures will develop a non-union.  These can be complex problems. The surgeon has to figure out why the fracture did not heal despite seemingly appropriate surgery.

Treatment of non-unions:  When a patient forms a non-union after having have had a surgery, the surgery needs to be repeated, i.e. revised. When the surgery is revised, such as in the case of the professional UFC fighter in the video below,  all the factors including the surgical technique, the plate, general health, and the postoperative protocol needs to be carefully considered.  The patient’s general health needs to be optimized, nicotine use must be completely stopped.  The plate and screw construct needs to be rigid.  The fracture ends need to be aligned and compressed firmly with the plate.  Bone graft or other bone forming (osteoinductive) grafts such as OP-1 or bone marrow aspirate should be used.  Lastly, an appropriate duration of post-surgical immobilization should be implemented. Typically after successful surgery new solid bone formation is seen within two months. After approximately three months the fracture is usually healed enough to resume progressive light impact.  The initial impact should be along the axis of the bone so no hammer blows or kick blocking or falling onto the outstretched arm is allowed.  After 6 months the fracture is usually rock solid and is able to tolerate most combat activities.

Ulna shaft, healed with plate
Successful revision surgical treatment of a prior failed plating. A longer plate provided greater rigidity was used. The fracture healed soon after the revision surgery.

Does the plate always need to be removed? Another consideration in mixed martial arts is whether or not to remove the plate once the fracture is healed.   This is due to the fact that in some cases, but not all, the healed ulna with the plate is at risk of a re-fracture.  Re-fractures can occur adjacent to the plate.  If the plate is removed once again a period of healing needs to be allowed before forceful activities are resumed.  Once the old screw holes are filled in with solid bone, full contact can be started. Because of the extended period of time that would be required for a fracture to heal after the plate is removed many fighters opt to leave the plate in and resume fighting.  The risk of a re-fracture is low in most situations.

My treatment approach is:

Hairline fracture- Attempt to treat the fracture without surgery by using a long arm cast and optimizing health.  If the fracture shows progression after 4-6 weeks I continue casting until the fracture is healed.  If there are no signs of healing  I will recommend surgery.

Displaced fractures- Surgical fixation with appropriate plate, apply good surgical technique to limit stripping of soft tissue, consider bone graft for fractures with multiple fragments and optimize the patient’s health.  The surgery is done as out-patient under general anesthesia.  A short period of post surgical casting is applied.  Progressive and appropriate striking allowed once fracture is solid.  Full contact combat competition allowed at approximately 6 months.  The plate might be removed if the location of the plate puts bone at high risk of re- fracture.

This fracture was successfully treated with plate fixation and then subsequent plate removal. The fracture has gone to to fully heal.

Patient testimonial: In this video professional UFC fighter Tony “El Cucuy” Ferguson talks about his forearm injury, treatment and recovery.  Tony’s forearm injury has gone on to successfully heal and has fought numerous times since his treatment.

Summary:  The good news regarding ulna shaft fractures in MMA athletes is that they can be treated successfully.  In my experience a displaced fracture will heal with appropriate plate fixation.  Attention to all adverse factors needs to be considered for a successful result.  In most cases patients can return to the highest level of competition.

I hope you found this information helpful.  Please let me know if I can be of service.

About Steve A. Mora MD:

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Dr. Mora is a native of Orange County. He graduated from Anaheim High School in Orange County CA. He received his medical education at UC Irvine College of Medicine where he finished in the top of his class earning the coveted AOA Medical Society honors. He completed his Orthopedic Surgery training LAC+USC Medical Center and then did a additional Sports Medicine Fellowship at the Santa Monica Orthopaedic and Sports Medicine Group where focused on sports medicine, shoulder, knee, hip arthroscopy.   He has published numerous book chapters on the topics of ACL injuries in soccer players, cartilage restoration, and athletic hip injuries.   He is currently practicing Orthopedic Surgery in the City of Orange Orange County.  He is a founding partner at Restore Orthopedics and Spine Center ( Dr. Mora’s practice focus is on sports related trauma, MMA injury treatment, arthroscopy of the shoulder, hip, knee and elbow, and partial and total knee replacement. He sees athletes of all levels including professional soccer and UFC/MMA patients. Dr. Mora’s family heritage is Peruvian. He speaks fluent Spanish.

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