Clinical Question

Is it possible to predict the likelihood of child abuse based on bruising characteristics detected on examination?

Evidence Summary

Among children four years and younger, 11,149 died from child abuse between 1999 and 2014.¹ That is a rate of 3.5 deaths per 100,000 children in this age group per year.¹ Bruising is the most common injury of child abuse to be overlooked or misdiagnosed before the death of a child due to abuse, representing a missed opportunity to intervene.² Although some bruising is expected in newly mobile children, especially below the knees and on the forehead, accidental bruising over other areas (e.g., ears, neck, genitalia) is rare.³ A clinical prediction rule that assists physicians in discriminating nonaccidental from accidental bruising could potentially prevent the morbidity and mortality associated with a missed diagnosis of child abuse. 

In 2010, a group from the University of Louisville proposed the TEN-4 Bruise Clinical Decision Rule to distinguish nonaccidental from accidental bruising in children four years and younger (Table 1).⁴ The group conducted a case-control study of 95 children admitted to a pediatric intensive care unit with trauma, 71 of whom had bruises. They found that a bruise on the torso, ear, or neck, or any bruise on a child younger than four months was considered suspicious. The TEN-4 rule correctly identified 32 of 33 children who had bruises as being abused, and 32 of 38 children who had bruises that were the result of an accident, for a sensitivity of 97% and a specificity of 84%.⁴