Tool distinguishes between abusive and nonabusive bruising


Bruising isn’t uncommon in children, but determining whether a bruise is from abuse or not is important. A report discusses the efficacy of a clinical decision tool.

In the rough and tumble world of childhood, blue and black markers are a rite of passage for many. However, bruising from physical abuse is the most common precursor injury that is either overlooked or misdiagnosed as nonabusive before either a near-fatality or abuse-related fatality in young children. A report in JAMA Network Open looked at whether a new bruising clinical decision rule named TEN-4-FACESp could lead to better, earlier detection of abuse.1

Investigators ran a prospective, observational, cross-sectional study that included patients aged younger than 4 years who had bruising. The children presented at 5 pediatric emergency departments. Children with known coagulation abnormalities, preexisting severe neuromuscular impairment resulting in spasticity, severe extensive skin disorders, or injuries from motor vehicle crashes were excluded from the study. Each child was given a deliberate skin exam and any child with at least 1 bruise was eligible to enroll. Skin findings were photographed; recorded on a body diagram; and catalogued according to type of skin injury, location of the skin injury, or whether the injury had a pattern. A total bruise count was also documented. An expert panel classified each case as abuse, nonabuse, or indeterminate.

A total of 21,123 children were screened for bruising with 2161 children enrolled in the study. The panel achieved a consensus on 2123 patients and classified 410 patients as abuse and 1713 as nonabuse cases. The median number of bruises seen were 3 per patient and patients who were abused had higher bruise counts than nonabuse patients. The previous method used TEN-4 rule was able to identify abuse in 331 of the 410 abuse patients and was also positive for 170 of the nonabuse patients. The sensitivity of the rule led to missing 19% of abuse cases, which suggested the need for a better tool. The new bruising clinical decision rule was 95.6% (95% CI, 93.0%-97.3%) sensitive and 87.1% (95% CI, 85.4%-88.6%) specific for distinguishing abuse from nonabusive trauma with patterned bruising, bruising anywhere on an infant aged 4.99 months and younger, and based on the body region bruised: torso, ear, neck, frenulum, angle of jaw, cheeks, eyelids, and subconjunctivae.

The investigators stated that they believe the rule is the first validated clinical decision rule that improved the recognition of physical abuse in young children who have bruising. They believe that implementing the rule in pediatric and general emergency departments and pediatric clinics could lead to less undue stress and improved recognition.


1. Pierce M, Kaczor K, Lorenz D, et al. Validation of a clinical decision rule to predict abuse in young children based on bruising characteristics. JAMA Netw Open. 2021;4(4):e215832. doi:10.1001/jamanetworkopen.2021.5832

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