brand logo

Am Fam Physician. 2022;105(6):661-662

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

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
Already a member/subscriber?  Log In


From $165
  • Immediate, unlimited access to all AFP content
  • More than 130 CME credits/year
  • AAFP app access
  • Print delivery available

Issue Access

  • Immediate, unlimited access to this issue's content
  • CME credits
  • AAFP app access
  • Print delivery available
Purchase Access:  Learn More

This guide is one in a series that offers evidence-based tools to assist family physicians in improving their decision-making at the point of care.

This series is coordinated by Mark H. Ebell, MD, MS, deputy editor for evidence-based medicine.

A collection of Point-of-Care Guides published in AFP is available at

Continue Reading

More in AFP

More in PubMed

Copyright © 2022 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.