Sentinel injury OSCE — recognising inflicted bruising in the non-mobile infant

Station objectives

1. Recognise a discriminating bruise and a sentinel injury in a non-mobile infant. [3] [2]
2. Apply the TEN-4 FACES-L rule and justify an abuse evaluation. [1] [5]
3. Construct and run the appropriate investigation and safeguarding pathway. [4]
4. Communicate with the family without accusation while completing the mandatory pathway. [4]

Candidate brief

You are the paediatric doctor in an acute assessment area. You have 12 minutes for Station A and 12 minutes for Station B. Examiners score recognition, safety and synthesis more than encyclopaedic lists. [4] [2]

Station A — Non-mobile infant

Setup: Caregiver and 3-month-old infant, seen for coryza. A 1.5 cm bruise behind the left ear is found on examination. The infant is not yet rolling independently. [3] [2]

Expected actions:

• Examine the child fully undressed; document the bruise on a body map with photography and measurement. [4]
• Recognise the ear as a TEN-4 region and the infant's non-mobile status; state that one positive feature triggers an abuse evaluation. [1] [5]
• Test the bouncy-chair mechanism against developmental plausibility and record the caregiver's words verbatim. [2]
• Arrange a skeletal survey with repeat at about two weeks and a coagulopathy panel; consider neuroimaging. [4]
• Refer to the child-protection team, make the mandatory report, and admit to a place of safety. [4] [2]

Station B — Toddler with multiple bruises

Setup: A 14-month-old with bruises on the cheek, the sternal area, and the shin, plus a torn upper labial frenum. A coagulation screen is normal. The family calls the child clumsy. [1] [9]

Expected actions:

• Apply TEN-4 FACES-L: cheek (C) and sternal area (S) are FACES sites; multiple regions; torn frenum is a high-specificity intra-oral finding. One positive feature triggers evaluation. [1] [5] [9]
• State that a normal coagulation screen does not close the case; run the bleeding-disorder differential in parallel with the safeguarding pathway. [11] [4]
• Test "clumsiness" against developmental plausibility rather than accepting it at face value. [4]
• Complete the full safeguarding response including sibling screening and verbatim documentation. [4] [2]

Marking anchors

Clear pass: recognises TEN-4 FACES-L trigger, non-mobile significance, full undressed exam, parallel bleeding-disorder work-up, mandatory pathway, safe disposition. [5] [4] Borderline: correct facts but accepts the first mechanism without testing plausibility, or treats the normal screen as closing the case. [11] Fail: attributes the ear bruise to the bouncy chair and discharges, or omits the skeletal survey and mandatory report, or confronts the caregiver in the corridor. [3] [4]

Debrief pearls

• Any bruise in a non-mobile infant is abnormal until proven otherwise. [3]
• One positive TEN-4 FACES-L feature is enough. [1] [5]
• A sentinel injury is a prior missed opportunity; act on it to prevent abusive head trauma. [2] [7]