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Beware High Risk Pediatric Bruising – TEN 4?

July 12, 2021

Written by Clay Smith

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High risk bruising is uncommon when mass screening a pediatric ED population, but when present is associated with a high prevalence of occult injury or subsequent confirmed abuse.

Why does this matter?
High risk bruising is any bruising in infants <4-6 months or bruising on the torso, ears, or neck if <48 months. A mnemonic is TEN 4 FACES P. Torso, Ears, Neck under 4 years, any bruising under 4 months OR injury to the Frenulum, Auricle, Cheek, Eyes, Sclera, or Patterned bruising. Hat tip to Tucker Anderson for making me aware of this mnemonic.

Beware high risk bruising
This was a retrospective study of 43,771 patients 0-48 months who presented to a pediatric ED and had nurse screening for bruising. Of these, 783 (1.8%) screened positive. Of the 8,635 infants <6 months, 48 (0.6%) had high risk bruising (i.e. any bruising). Half of these were considered due to abuse. The protocol was to get a skeletal survey on any child with high risk bruising. However, that was only done in 29 of the 48 children, and 11 of those 29 (38%) had occult fracture. In the 35,136 children 6 month to <48 months, 115 (0.3%) had high-risk bruising and 32 of 115 (28%) went on to be diagnosed with likely or definite abuse. You won’t see high risk bruising often, but when you do, it is worth investigating. Because among patients with high risk bruising, the prevalence of other other occult injuries was high, and the prevalence of likely or confirmed abuse in these cases was high as well.

Evaluation of an Emergency Department High-risk Bruising Screening Protocol. Pediatrics. 2021 Mar 2;147(4):e2020002444. doi: 10.1542/peds.2020-002444. Epub ahead of print.

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