Paeds · child-safety-and-social-paediatrics
Physical abuse: bruising and sentinel injuries
Also known as Non-accidental bruising · Inflicted soft-tissue injury · TEN-4 FACES-L bruising rule · Sentinel injury recognition · Bruising in suspected child abuse
A fellowship-level, exam-exhaustive approach to inflicted bruising and sentinel injuries: the TEN-4 FACES-L decision rule, the significance of any bruise in a non-mobile infant, patterned and high-specificity injury, the differential (including bleeding disorders), skeletal survey and coagulopathy work-up, mandatory reporting and the safeguarding pathway across ANZ, UK, US and Canada.
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Target exams
Red flags
- Any bruise in a non-mobile infant (not yet independently cruising)
- Bruise on a TEN-4 region — torso, ear, neck — or a FACES site in any child
- Four or more body regions of bruising, or a large bruise in an infant
- Patterned injury — hand-slap, ligature, bite, implement imprint
- A sentinel injury: unexplained bruise, intra-oral injury, or fracture in an infant
- Mechanism that does not match the child's developmental ability
Life stages
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Clinical exam formats
Board mappings
- General and Community Paediatrics
- Current 2026 PREP curriculum — Learning goal 9: Clinical assessment and management – child safety and maltreatment
- Current 2026 PREP curriculum — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 9: Clinical assessment and management – child safety and maltreatment
- Clinical Applications
- Long Cases
- Short Cases
- 9. Safeguarding vulnerable children
- General Paediatrics: Recognises, investigates and manages safeguarding issues
- 8. Health promotion and illness prevention
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- History
- Communication
- Clinical
- General Pediatrics Content Outline — Domain 8: Child Abuse and Neglect
- General Pediatrics Content Outline — Domain 3: Injury, Violence, and Poison Prevention
- General Pediatrics EPA: Recognizing and managing suspected child maltreatment and/or neglect
- Patient Care 4: Clinical Reasoning
- Professionalism 1: Professional Behavior and Ethical Principles
- Systems-Based Practice 2: Patient safety and systems-based improvement
- Pediatrics: Core EPA #8 — Recognizing and managing suspected child maltreatment and/or neglect
- Medical Expert
- Health Advocate
Accidental vs inflicted bruising
Accidental
Inflicted
Overview & Definition
Physical abuse is inflicted injury, and for the bedside clinician the first and most common evidence is the skin. Bruising is the most frequent manifestation of physical abuse and the most easily missed. The job of the clinician is not to convict a caregiver but to recognise when a pattern of bruising is improbable as an accident and must trigger a structured safeguarding response. [1] [4]
Two linked concepts anchor this page. The first is the discriminating bruise — a bruise whose location, number, shape or size raises the probability of inflicted injury high enough to mandate an evaluation. The TEN-4 FACES-L clinical decision rule operationalises that judgement. The second is the sentinel injury, defined as a minor injury seen in a pre-mobile infant that is poorly explained and that, on later review, is understood to have been inflicted. [2] [5]
The reason sentinel injuries matter is prevention. Infants who later present with abusive head trauma or major inflicted injury have often had a prior, smaller injury that a clinician saw and explained away. Recognising the sentinel injury and acting on it is one of the few points in child protection where a clinician can intervene before catastrophe. [2] [7]
This page owns recognition and the immediate safeguarding response for bruising and sentinel soft-tissue injury. It cross-links to dedicated pages on abusive head trauma, inflicted fractures, inflicted burns, intra-oral injury, and mandatory reporting. It does not duplicate those workups. [4]
References11ShowHide
- [1]Pierce MC Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics, 2010.PMID 19969620
- [2]Sheets LK Sentinel injuries in infants evaluated for child physical abuse. Pediatrics, 2013.PMID 23478861
- [3]Sugar NF Bruises in infants and toddlers: those who don't cruise rarely bruise. Puget Sound Pediatric Research Network. Archives of pediatrics & adolescent medicine, 1999.PMID 10201724
- [4]Christian CW The evaluation of suspected child physical abuse. Pediatrics, 2015.PMID 25917988
- [5]Pierce MC Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. JAMA network open, 2021.PMID 33852003
- [6]Petska HW Sentinel injuries: subtle findings of physical abuse. Pediatric clinics of North America, 2014.PMID 25242706
- [7]Letson MM Prior opportunities to identify abuse in children with abusive head trauma. Child abuse & neglect, 2016.PMID 27680755
- [8]Ruiz-Maldonado TM Palm Bruising in Infants: A Recognizable Pattern of Abuse. The Journal of emergency medicine, 2021.PMID 33795168
- [9]Maguire S Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries. Archives of disease in childhood, 2007.PMID 17468129
- [10]Maguire SA A systematic review of abusive visceral injuries in childhood--their range and recognition. Child abuse & neglect, 2013.PMID 23306146
- [11]Hultman L Testing for bleeding disorders in child abuse: AAP recommendation adherence and testing results. Child abuse & neglect, 2025.PMID 40158474