1 Introduction

Combat sports–including traditional forms (e.g., judo, taekwondo, and karate) and Western variants (e.g., boxing, wrestling, mixed martial arts)–are organized athletic disciplines involving full or restricted physical contact through striking, grappling, or some combination of both. Participation in these sports has grown significantly in the United States over the last couple of decades, driven by increased youth participation, a growing commitment to legal safety regulations, and the mainstream popularity of organizations like the Ultimate Fighting Championship (UFC) and World Wrestling Entertainment (WWE).^1,2 Notably, according to the National Federation of State High School Associations (NFHS), wrestling represents the sixth most popular sport among boys in U.S. high schools.³ Survey estimates from 2024 indicate approximately seven million individuals participate in martial arts (MA) and nearly nine million in boxing across the U.S.^4,5 While combat sports have been demonstrated to offer physical and psychosocial benefits–ranging from improved aerobic capacity and flexibility to enhanced self-regulation and decreased aggression–they are also inherently high-risk activities due to the intense nature of bodily contact.⁶

Among the spectrum of injuries sustained during combat sport participation, fractures constitute a clinically relevant subset. Fractures sustained in combat sports can have significant implications for athletes, affecting both immediate performance and long-term career trajectories. These injuries often require long recovery periods, with some leading to permanent reductions in athletic capabilities or career-ending outcomes.⁷

General injury trends across various combat sports in both pediatric and adult populations are well-documented ^1,8–13, and some studies^14,15 have examined differences in injury rates and patterns between MA disciplines. However, few investigations have stratified by discipline to assess how fracture injuries vary across demographic factors such as age and sex or to elucidate patterns in anatomical distribution. Additionally, much of the existing literature is limited by small sample sizes or focuses primarily on injuries sustained by professional athletes or tournament participants, which may not reflect the general population of participants ^16–19. Pappas²⁰ reported injury rates–including fractures–across boxing, wrestling, and MA treated in U.S. emergency departments from 2002 to 2005; however, the study did not include comparative analyses by demographic characteristics or anatomical injury sites.

Increasingly, much attention from medical experts has centered on the risk of chronic traumatic brain injury, particularly in boxing ^21–23. Prior studies have elucidated differences in the incidence of individual combat sport-related facial injuries and mild traumatic brain injuries presenting to U.S. emergency departments, offering insights that can inform sports-specific safety strategies and regulatory policies aimed at injury prevention.^24,25 Identifying such nuances in fracture injury patterns in the domain of combat sports could inform sport-specific, age-appropriate prevention strategies and safety regulations. At present, large-scale studies specifically investigating combat sport-related fractures in depth are limited.

To address this gap, the United States Consumer Product Safety Commission's (CPSC) National Electronic Injury Surveillance System (NEISS) was queried to analyze a nationally representative sample of emergency department visits for combat sport-related fractures. The objectives of this study were to (1) determine the incidence and demographic characteristics of combat sport-related fractures treated in U.S. emergency departments and (2) compare demographic variables, injury characteristics, and disposition among boxing-, wrestling-, and MA-related fractures.

2 Methods

3 Results

3.1

3.1 Fracture incidence and characteristics

From 2014 to 2023, a total of 22,233 combat sport-related injuries were recorded, corresponding to a weighted national estimate of 80,182 injuries annually (Table 1). Among these, 4391 (19.7%) were fractures, including 929 (21.2%) related to boxing, 1938 (44.1%) to wrestling, and 1524 (34.7%) to MA (Fig. 1). This equates to an estimated 14,555 combat sport-related fractures occurring annually nationwide. Table 2 and Fig. 2 present the annual frequency of fractures. Of the 4391 fractures, 85.2% occurred in males, while 14.8% occurred in females (Table 3). The mean age at the time of fracture was 19.15 ± 11.36 years. Overall, the hand (15.9%), lower arm (11.0%), shoulder (10.2%), and fingers (10.1%)–which are categorized separately from the hand in the database–constituted the most frequent sites of fracture. Of all patients presenting with combat sport-related fractures, 93.0% were treated/examined and released.

Table 1 Frequency of total combat sport-related injuries and national estimates from 2014 to 2023.

Injury Type	No. of Injuries	National Estimates
Fractures	4391 (19.7)	145,550 (18.2)
Non-fractures	17,842 (80.3)	656,268 (81.8)
Total	22,233 (100.0)	801,818 (100.0)

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Fig. 1 Proportion of combat sport-related fractures from 2014 to 2023 by sport.

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Table 2 Annual frequency of combat sport-related fractures from 2014 to 2023.

Year	No. of Fractures
2014	426 (9.7)
2015	400 (9.1)
2016	456 (10.4)
2017	584 (13.3)
2018	422 (9.6)
2019	461 (10.5)
2020	265 (6.0)
2021	385 (8.8)
2022	466 (10.6)
2023	526 (12.0)
Total	4391 (100.0)

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Fig. 2 Annual frequency of combat sport-related fractures from 2014 to 2023.

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Table 3 Combat sport-related fractures from 2014 to 2023 by patient sex.

Sex	No. of Fractures	No. of Injuries	Fractures as % of Injuries
Male	3742 (85.2)	18,235 (82.0)	20.5
Female	649 (14.8)	3997 (18.0)	16.2
Non-binary/Other	0 (0.0)	1 (<0.01)	0.0
Total	4391 (100.0)	22,233 (100.0)	19.7

3.2

3.2 Injury patterns by sport

Fractures constituted a higher proportion of total injuries in boxing (21.6%) than in wrestling (19.6%) and MA (19.0%) (Fig. 3; p = 0.002). The mean age at the time of fracture was highest in the boxing group (25.18 ± 11.49 years) compared to the MA (20.71 ± 14.12 years) and wrestling (15.04 ± 6.02 years) groups (Table 4; p < 0.001). Fracture location varied significantly by sport (Table 4; p < 0.001). Boxing-related fractures most commonly involved the hand (50.4%), followed by the face (15.3%) and fingers (10.3%). Wrestling-related fractures were most common in the shoulder (15.7%), followed by the lower arm (14.6%), fingers (10.9%), and elbow (9.7%). MA-related fractures most frequently affected the toes (15.9%)–which are categorized separately from the foot–followed by the lower arm (10.8%).

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Fig. 3 Distribution of combat sport-related injuries from 2014 to 2023 by sport and injury type.

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Table 4 Patient demographics and injury characteristics for combat sport-related fractures from 2014 to 2023 by sport.

Variable	Boxing Fractures (N = 929)	Wrestling Fractures (N = 1938)	Martial Arts Fractures (N = 1524)	P
Sex				<0.001
Male	832 (89.6)	1804 (93.1)	1106 (72.6)
Female	97 (10.4)	134 (6.9)	418 (27.4)
Affected Body Part				<0.001
Head	4 (0.4)	8 (0.4)	7 (0.5)
Face	142 (15.3)	102 (5.3)	121 (7.9)
Neck	0 (0.0)	18 (0.9)	3 (0.2)
Shoulder	9 (1.0)	304 (15.7)	134 (8.8)
Upper Arm	10 (1.1)	146 (7.5)	30 (2.0)
Elbow	11 (1.2)	187 (9.7)	56 (3.7)
Lower Arm	35 (3.8)	283 (14.6)	164 (10.8)
Wrist	76 (8.2)	122 (6.3)	128 (8.4)
Hand	468 (50.4)	100 (5.2)	128 (8.4)
Finger	96 (10.3)	211 (10.9)	136 (8.9)
Upper Trunk	35 (3.8)	45 (2.3)	67 (4.4)
Lower Trunk	2 (0.2)	20 (1.0)	14 (0.9)
Pubic Region	0 (0.0)	0 (0.0)	1 (0.1)
Upper Leg	1 (0.1)	10 (0.5)	10 (0.7)
Knee	6 (0.7)	20 (1.0)	16 (1.1)
Lower Leg	6 (0.7)	149 (7.7)	75 (4.9)
Ankle	5 (0.5)	137 (7.1)	78 (5.1)
Foot	11 (1.2)	36 (1.9)	113 (7.4)
Toe	12 (1.3)	39 (2.0)	243 (16.0)
Unknown	0 (0.0)	1 (0.1)	0 (0.0)
Age Group				<0.001
Pediatric (<18)	282 (30.4)	1710 (88.2)	858 (56.3)
Adult (≥18)	647 (69.6)	228 (11.8)	666 (43.7)
Mean Age	25.18 ± 11.49	15.04 ± 6.02	20.71 ± 14.12	<0.001
Disposition Status				<0.001
Treated/Examined and Released	895 (96.3)	1769 (91.3)	1421 (93.2)
Treated and Transferred	2 (0.2)	16 (0.8)	10 (0.7)
Treated and Admitted/Hospitalized	24 (2.6)	147 (7.6)	84 (5.5)
Held for Observation	6 (0.7)	5 (0.3)	4 (0.3)
Left Without Being Seen	2 (0.2)	1 (0.1)	5 (0.3)

3.3

3.3 Injury patterns by age group

Pediatric (<18 years) patients accounted for 64.9% of all combat sport-related fractures, with lower arm (15.2%) and shoulder (14.0%) fractures being the most prevalent in this group, whereas adults were most likely to sustain hand (31.0%) and face (15.1%) fractures (Fig. 4; Table 5; p < 0.001). Fractures related to both wrestling (88.2%) and MA (56.3%) were predominantly observed in pediatric patients, while boxing-related fractures occurred more frequently among adults (69.6%) (Table 4; p < 0.001). Among adults, MA-related fractures accounted for the largest proportion (43.2%), while wrestling-related fractures represented the majority (60.0%) of pediatric cases (Table 4; p < 0.001).

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Fig. 4 Frequency of combat sport-related fractures from 2014 to 2023 by age group.

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Table 5 Affected body part in pediatric versus adult patients with combat sport-related fractures from 2014 to 2023.

Affected Body Part	Pediatric (<18)	Adult (≥18)
Head	10 (0.4)	9 (0.6)
Face	133 (4.7)	232 (15.1)
Neck	14 (0.5)	7 (0.5)
Shoulder	399 (14.0)	48 (3.1)
Upper Arm	137 (4.8)	49 (3.2)
Elbow	225 (7.9)	29 (1.9)
Lower Arm	434 (15.2)	48 (3.1)
Wrist	241 (8.5)	85 (5.5)
Hand	219 (7.7)	477 (31.0)
Finger	302 (10.6)	141 (9.1)
Upper Trunk	42 (1.5)	105 (6.8)
Lower Trunk	25 (0.9)	11 (0.7)
Pubic Region	0 (0.0)	1 (0.1)
Upper Leg	20 (0.7)	1 (0.1)
Knee	30 (1.1)	12 (0.8)
Lower Leg	182 (6.4)	48 (3.1)
Ankle	144 (5.1)	76 (4.9)
Foot	107 (3.8)	53 (3.4)
Toe	185 (6.5)	109 (7.1)
Unknown	1 (0.0)	0 (0.0)
Total	2850 (100.0)	1541 (100.0)

4 Discussion

Over the 10-year period, a total of 4391 combat sport-related fractures were identified in the NEISS database, corresponding to an estimated 14,555 such injuries occurring annually across the U.S. These findings highlight the substantial public health burden posed by fracture injuries in combat sports and reinforce the need for surveillance and prevention efforts. The annual frequency of fractures showed no clear upward or downward trend over the 10-year period, though 2020 was a notable outlier, likely due to the COVID-19 pandemic.

Consistent with prior findings²⁰ that combat sports carry a high risk of injury due to their inherent physical demands, this study found that nearly one in five combat sport-related emergency department visits involved a fracture. Wrestling accounted for the largest proportion of these fractures, followed by MA and boxing. Notably, although boxing accounted for the fewest total injuries, it had the highest proportion of fractures among all injuries at 21.6%, with a predominance of hand fractures (50.4%). This is consistent with previous data²⁰ and the known biomechanical vulnerability of the hand to fractures in boxing, particularly fifth metacarpal fractures–commonly known as boxer's fractures–which occur due to the strong axial force transmitted through the metacarpal bone when the fist is clenched.²⁷

Notably, a meta-analysis of 14 studies on boxing-related injuries by Mao et al. reported a pooled fracture incidence of 11.4% across all injuries.¹⁰ While most studies in the analysis focused on competitive boxing, the authors observed a markedly higher proportion of fractures among injuries specifically related to punching bag use. They proposed that the lower overall fracture rate in their review compared to NEISS-based studies^8,20 may reflect the exclusion of non-competitive incidents in most of the analyzed studies–such as warm-ups or training–which are captured collectively in the NEISS database.

Males accounted for the vast majority of fractures–likely due in part to participation trends–and were significantly more likely than females to sustain fractures among all injury types. Hand fractures were the most common among males, while shoulder fractures were the most frequent among females. Age also emerged as a significant factor in the distribution of fractures. The majority of fractures in wrestling and MA occurred in pediatric patients, while boxing-related fractures were more common in adults and occurred at a significantly higher mean age. These patterns likely reflect the prevalence of wrestling and MA in youth programs and high school athletics, as well as differences in regulatory oversight and youth participation recommendations. Particularly, the American Academy of Pediatrics (AAP) has recommended against boxing participation for children and adolescents in recent years, emphasizing the risk of head injuries.²⁸

Importantly, the Amateur International Boxing Association (AIBA), now the International Boxing Association (IBA), banned the use of headgear for male senior boxers in 2013–aligning it more with professional boxing–citing evidence that headgear may actually increase the risk of concussions and head injuries.²⁹ A systematic review by Tjønndal et al. examined studies on the use of protective headgear in boxing and found limited evidence for or against its effectiveness in preventing head injuries.³⁰ The review did, however, note a lower incidence of facial lacerations and skull fractures with headgear use. Overall, the impact of the rule change on the incidence of head and facial fractures in amateur and professional boxers is inconclusive, and any emerging trends in these participants are unlikely to be reflected in NEISS data. Nonetheless, these questions underscore the link between rules of participation and injury patterns. In the present study, head and facial fractures comprised approximately 15% of all boxing-related fractures, the highest proportion among the three sports analyzed. Hojjat et al. found that wrestlers had the highest rate of facial injuries overall, whereas boxers exhibited the highest proportion of facial fractures relative to total injuries.²⁴

The anatomical distribution of fractures also differed markedly by sport. In addition to the high prevalence of hand fractures in boxing, shoulder and lower arm fractures predominated in wrestling, while toe and lower arm fractures were most frequent in MA. These variations likely reflect the mechanics unique to each sport: wrestling involves frequent takedowns and ground-based movements with forceful impact to the shoulder and upper extremities, while MA incorporates various striking and kicking techniques, explaining the frequency of toe injuries. This level of anatomical specificity in fracture reporting, particularly when stratified by combat sport, has not been extensively reported in prior NEISS-based analyses.

Regarding patient disposition, the vast majority of fracture cases were treated and released from the emergency department, with only a small proportion requiring hospitalization. Interestingly, boxing-related fractures were the least likely to result in admission. This may reflect a higher proportion of non-displaced fractures that do not require surgical intervention. Conversely, wrestling-related fractures had the highest rate of hospitalization, potentially reflecting more high-impact falls or more complex injuries, particularly in the pediatric population. Future studies incorporating mechanisms of injury and fracture type and severity data can help clarify these findings.

These findings have practical implications for clinicians, coaches, trainers, and regulatory bodies. Understanding sport-specific injury trends can guide the development of preventive strategies such as improved protective equipment, changes in training protocols, or modifications to rulebooks. For example, reinforcing protective techniques during wrestling takedowns or emphasizing proper striking mechanics in boxing may reduce the incidence of fractures. Furthermore, clinicians treating combat athletes–particularly in the emergency setting–should be cognizant of sport-specific fracture patterns when evaluating injuries.

5 Limitations

This study is subject to several limitations, many inherent to the NEISS database. First, the dataset is limited to injuries seen at emergency departments and does not capture fractures treated in urgent care or outpatient settings. Second, the clinical detail is limited, as information on fracture classification, severity, and treatment type is not available. Moreover, follow-up data regarding recovery or return to sport is absent. Combined with the lack of data on injury mechanisms, these gaps complicate efforts to identify patterns essential for guiding effective prevention and treatment approaches. The coding system utilized by the database captures all injuries associated with the sport, creating a risk of skewed data by including injuries from training, equipment, or other non-competitive activities rather than solely those sustained during true competition. Also, MA encompasses a variety of styles that are not differentiated within the database, an important limitation since prior research has identified varying injury patterns specific to different MA disciplines.¹⁵ Additional limitations exist beyond those associated with the NEISS database. Though the database allows for a comparison of fractures to total injuries, there was no accurate and reliable method to estimate the number of participants in each combat sport to establish true incidence rates. Future investigations should aim to address these remaining questions. Despite these limitations, the NEISS database provides a nationally representative, population-based sample, allowing this 10-year study to offer valuable longitudinal insights into combat sport-related fracture patterns.

6 Conclusion

Combat sport-related fractures exhibit distinct injury patterns based on sport, age group, and sex. Boxers sustained the highest proportion of fractures out of total injuries, primarily affecting the hand, while wrestling-related fractures occurred predominantly in pediatric patients and often involved the shoulder. Males accounted for the vast majority of fractures across all sports, with differing injury patterns compared to females. Patients treated for boxing-related fractures were the most likely to be treated/examined and released. These findings provide valuable insights for targeted injury prevention and sport-specific safety strategies.

Patient consent

Patient consent was not required for this study, as it utilized publicly available, de-identified data from the National Electronic Injury Surveillance System (NEISS). The dataset contains no direct or indirect patient identifiers, and all information is anonymized prior to public release.

Ethical statement

The present study involved secondary analysis of publicly available, de-identified data obtained from the National Electronic Injury Surveillance System (NEISS). No direct or indirect identifiers were included. As such, institutional review board approval and informed consent were not required. The use of this data complies with relevant ethical guidelines, legal requirements, and the principles of the Declaration of Helsinki, and the privacy rights of individuals represented in the dataset were fully protected.

Author contribution

Zayd Chishti: Conceptualization, Methodology, Investigation, Writing – Original Draft, Writing – Review & Editing.

Albert Brotgandel: Conceptualization, Methodology, Investigation, Writing – Original Draft, Writing – Review & Editing.

Carson Balen: Conceptualization, Methodology, Investigation, Writing – Original Draft, Writing – Review & Editing.

Rebecca Lipscomb: Methodology, Investigation, Formal Analysis, Writing – Review & Editing.

D. Trey Remaley: Methodology, Writing – Review & Editing, Supervision.

John Kiel: Methodology, Writing – Review & Editing, Supervision.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.