In this episode we learn how to recognize concerning bruising using the TEN-4-FACESp rule. TEN-4-FACESp is an important rule that teaches us to recognize abnormal bruising and is a clinical tool that helps us decide whether further investigation for child abuse is warranted.

This episode was written by pediatric resident Megan Branson, and pediatricians Tammy Yau and Lidia Park with content support from Julia Magana, a pediatric emergency medicine physician and child abuse specialist. Pediatricians Tammy and Lidia take full responsibility for any errors or misinformation.

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Key Points:

• The TEN-4-FACESp rule highlights high-risk bruising: torso, ears, neck, any bruise in infants ≤4 months, and facial areas (frenulum, angle of jaw, cheeks, eyelids, subconjunctivae), plus patterned bruising
• Evaluation should include a thorough, neutral history, full skin exam, and consideration of medical causes (e.g., ITP, bleeding disorders), while remembering this is a screening tool—not diagnostic of abuse.
• This tool can help learners understand more about child abuse and develop their skills for recognizing it in their patients:
• https://emscimprovement.center/news/introducing-peak-child-abuse-a-free-educational-toolkit/