Can TEN4 distinguish bruises from abuse, inherited bleeding disorders or accidents?

OBJECTIVE: Does TEN4 categorisation of bruises to the torso, ear or neck or any bruise in <4-month-old children differentiate between abuse, accidents or inherited bleeding disorders (IBDs)? DESIGN: Prospective comparative longitudinal study. SETTING: Community. PATIENTS: Children <6 years old. INTERVENTIONS: The number and location of bruises compared for 2568 data collections from 328 children in the community, 1301 from 106 children with IBD and 342 abuse cases. MAIN OUTCOME MEASURES: Likelihood ratios (LRs) for the number of bruises within the TEN and non-TEN locations for pre-mobile and mobile children: abuse vs accidental injury, IBD vs accident, abuse vs IBD. RESULTS: Any bruise in a pre-mobile child was more likely to be from abuse/IBD than accident. The more bruises a pre-mobile child had, the higher the LR for abuse/IBD vs accident. A single bruise in a TEN location in mobile children was not supportive of abuse/IBD. For mobile children with more than one bruise, including at least one in TEN locations, the LR favouring abuse/IBD increased. Applying TEN4 to collections from abused and accidental group <48 months of age with at least one bruise gave estimated sensitivity of 69% and specificity for abuse of 74%. CONCLUSIONS: These data support further child protection investigations of a positive TEN4 screen in any pre-mobile children with a bruise and in mobile children with more than one bruise. TEN4 did not discriminate between IBD and abuse, thus IBD needs to be excluded in these children. Estimated sensitivity and specificity of TEN4 was appreciably lower than previously reported.