Child Injuries: Is It an Accident or Abuse? How to Recognize the Difference

Kids get hurt. They fall, bump into things, and get scrapes and bruises as they grow.

But some injuries are not accidents. They may be caused by child abuse—also called child maltreatment (World Health Organization [WHO], 2023; WHO, 2022).

This article is meant to help you:

• Understand what child abuse is

• Notice patterns of injuries that may be more suspicious

• Know when to speak up and get help

  
  

It is not meant for anyone trying to hide abuse. It is meant to protect children.

What Is Child Abuse?

Organizations like WHO and the American Academy of Pediatrics define child maltreatment as (WHO, 2023; WHO, 2022):

Any physical, emotional, or sexual abuse, neglect, or exploitation of a child (under age 18) that harms or may harm the child’s health, development, or dignity—especially when done by a parent, caregiver, or other person in a position of trust or power.

Child abuse can include:

• Physical abuse – hitting, shaking, burning, or otherwise causing bodily harm

• Emotional / psychological abuse – constant belittling, threats, or rejection

• Sexual abuse or exploitation

• Neglect – not providing needed food, shelter, medical care, or supervision

  
  

This article focuses mostly on physical abuse and how to tell if an injury might be more than “just an accident.” (WHO, 2023; WHO, 2022)

Kids Do Get Hurt: What Accidental Injuries Often Look Like

Healthy, active children do get bumps and bruises. Normal, accidental injuries often:

• Match the story of what happened

• Fit the child’s development (what they can do at their age)

• Show up in common places where kids tend to get hurt

  
  

For example (National Institute of Justice [NIJ], 2023; Children’s Hospital Colorado, 2024):

• A toddler learning to walk may have bruises on the shins and forehead.

• A school-age child might have scrapes on knees and elbows from playing outside.

  
  

These injuries usually:

• Are on bony areas (shins, knees, elbows, forehead)

• Have a reasonable explanation that matches the child’s age and activity

• Heal in a way that makes sense over time (NIJ, 2023; Children’s Hospital Colorado, 2024)

  
  

When an Injury Might Be Abuse: Red Flags

Some patterns are more likely to be seen in physical abuse. No single sign proves abuse by itself, but multiple red flags together should raise concern.

1. The Story Doesn’t Match the Injury

Healthcare guidelines suggest being alert when (NIJ, 2023; WHO, 2022; Children’s Hospital Colorado, 2024):

• The explanation keeps changing

• The story doesn’t fit the type or severity of injury

• The story is not consistent with the child’s age

  • Example: a 3-month-old “rolled off the couch and broke a thigh bone” (but 3-month-olds can’t roll far)

• There is no explanation at all, or the caregiver says “I don’t know” for a serious injury

  
  

When the history doesn’t make sense, professionals are trained to think about abuse as one possible cause.

2. Injuries in Unusual Places (TEN-4-FACESp Rule)

Research shows that certain bruise locations are more likely to be from abuse, especially in children under 4 years old and in infants who are not yet walking (Pierce et al., 2013; Pierce et al., 2024; Lurie Children’s Hospital, 2024).

Experts use a tool called TEN-4-FACESp to help remember high-risk bruising patterns (Lurie Children’s Hospital, 2024; JAMA Network Open, 2021):

• T – Torso (chest, belly, back, buttocks, genitals)

• E – Ears

• N – Neck

• 4 – Any bruise on a child 4 months old or younger (anywhere on the body)

• FACES –

  • Frenulum (small fold of skin under the tongue or upper lip)

  • Angle of jaw

  • Cheeks

  • Eyelids

  • Sclera (white part of the eye)

• p – Patterned bruises (shaped like a hand, belt, cord, or object)

  
  

Bruises in these regions—especially in a baby who can’t crawl, pull to stand, or walk yet—are considered “sentinel injuries” and need careful evaluation (Sheets et al., 2013; Pierce et al., 2024).

3. “Sentinel Injuries” in Babies and Young Children

A sentinel injury is a relatively small injury that may be the first visible sign of abuse and can happen before more serious harm (Sheets et al., 2013; ACEP, 2023).

Examples in infants include:

• Small bruises on the face, ears, or neck

• Torn frenulum (under the tongue or lip) with no clear explanation

• Bruises in a baby who is not yet mobile (“pre-cruising”)

  
  

Studies have found that a significant number of infants who later suffer severe abusive injuries (like head trauma) had earlier sentinel injuries that were missed or dismissed (Sheets et al., 2013; Casey Family Programs, 2020; Pierce et al., 2017).

Key idea:

Babies who don’t crawl don’t bruise—so any unexplained bruise in a non-mobile infant deserves serious attention.

4. Fractures and Other Serious Injuries

Fractures (broken bones) can be accidental—but they can also be caused by abuse. The American Academy of Pediatrics highlights that (American Academy of Pediatrics [AAP], 2014; AAP, 2024):

• Some fractures are more concerning in young children, especially if:

  • The child is very young (under 1–2 years) and not yet walking

  • The fracture type or location doesn’t fit the story

  • There are multiple fractures at different stages of healing

    
    

Common injuries that raise concern include:

• Rib fractures

• Certain skull or long-bone fractures in non-mobile infants

• Injuries to multiple body areas at once

  
  

When these are found, careful evaluation is recommended to look for abuse and other medical causes (AAP, 2014; AAP, 2024).

Important: Abuse Can Be Missed and Misdiagnosed

Professionals must balance two serious risks (AAP, 2024; WHO, 2022; NIJ, 2023):

1. Missing real abuse, leaving a child in danger

   
   

2. Wrongly labeling a family as abusive when an injury was accidental or due to a medical condition

   
   

That’s why doctors are urged to:

• Take a careful history

• Do a full physical exam

• Use appropriate imaging and lab tests

• Consider bone diseases, bleeding disorders, and other conditions that might explain injuries

  
  

As a caregiver, teacher, nurse, or neighbor, your role is not to diagnose.Your role is to notice red flags and report concerns so trained teams can investigate.

What You Can Do If You’re Worried About a Child

If you see injuries or behavior that worry you:

1. Trust your instincts.If it doesn’t feel right, it’s okay—and important—to speak up.

   
   

2. If the child is in immediate danger, or has:

   
   

   • Trouble breathing

   • Unconsciousness

   • Severe bleeding

   • Suspected head injury or broken bones→ Call 911 (in the U.S.) or your local emergency number right away.

     
     

3. Report your concerns to child protective services or your local child abuse hotline.

   
   

   • In many places, healthcare workers, teachers, and some other professionals are legally required (mandated) reporters.

   • You can usually report even if you are not sure, as long as you report in good faith (WHO, 2022; national child protection laws).

     
     

4. Document what you see (if you are a professional).

   • Note the date, time, and what you observed or heard.

   • Use the child’s own words if they disclose something.

     
     

Remember:

Reporting is about protecting the child and allowing trained professionals to investigate. It is not the same as accusing someone by yourself.

Tee Shirt: Education You Can Wear (Child Abuse Awareness Tee)

Talking about child abuse is uncomfortable—but staying silent can be dangerous. Many children never tell anyone, and their injuries may be mislabeled as “just accidents” (WHO, 2023; WHO, 2022).

That’s why NurseMob’s child abuse awareness tee is designed as education you can wear.

This kind of tee can highlight key messages like:

• “Bruises in babies who can’t crawl are NOT normal.”

• “TEN-4-FACESp: High-risk bruising areas in kids under 4. Know them.”

• “See something that doesn’t fit the story? Speak up.”(Pierce et al., 2013; Lurie Children’s Hospital, 2024; NIJ, 2023; WHO, 2022)

  
  

When worn by:

• Nurses, doctors, and social workers

• Teachers and school staff

• Community advocates, foster parents, or family support workers

  
  

this tee can:

• Start important conversations:

  “What does TEN-4-FACESp on your shirt mean?”

• Help caregivers learn that some bruises and injuries are more concerning than others

• Encourage more people to report early, before minor injuries turn into severe harm

  
  

The more child abuse awareness tees out in public:

• The more people learn to spot sentinel injuries and high-risk bruising patterns

• The less likely subtle signs are to be ignored

• The more chances we have to protect children before the abuse escalates

  
  

You can find this tee (and other “education you can wear” designs) in the NurseMob shop, created by a nurse to blend solid medical information, child safety, and advocacy.

If You Are a Parent or Caregiver Who Is Struggling

If you are reading this and think:

“I’m afraid I might lose control with my child,”or“I’ve already hurt my child and I don’t know what to do.”

you deserve support, not shame.

• Talk to a healthcare provider, therapist, or social worker and say:

  “I am overwhelmed and afraid I might hurt my child. I need help now.”

• Ask about:

  • Parenting support programs

  • Stress and anger management resources

  • Home visiting or family support services

    
    

Many programs are designed to:

• Help parents cope with stress, mental health issues, or substance use

• Keep children safer at home whenever possible (WHO, 2023; WHO, 2022)

  
  

Seeking help is a sign of strength, not failure.

Child Abuse

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Key References

American Academy of Pediatrics (AAP). (2014). Evaluating children with fractures for child physical abuse. Pediatrics, 133(2), e477–e489.

American Academy of Pediatrics (AAP). (2024). Evaluating young children with fractures for child abuse: Clinical report. Pediatrics, 155(2), e2024-070074.

Casey Family Programs. (2020). Do sentinel injuries predict later physical abuse in infants?

Children’s Hospital Colorado. (2024). Physical abuse: Bruises, breaks, burns, belly trauma.

Jankowiak-Siuda, K., et al. (2024). Identifying inflicted injuries in infants and young children. Pediatric Clinics.

Lurie Children’s Hospital. (2024). TEN-4-FACESp bruising clinical decision rule.

National Institute of Justice (NIJ). (2023). Child trauma: Determining accidental injury from intentional abuse.

Pierce, M. C., et al. (2013). Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics, 131(1), 67–74.

Pierce, M. C., et al. (2024). Single bruise characteristics associated with abusive vs accidental injury. Pediatrics, 155(3), e2024067932.

Sheets, L. K., et al. (2013). Sentinel injuries in infants evaluated for child physical abuse. Pediatrics, 131(4), 701–707.

World Health Organization. (2022). Responding to child maltreatment: A clinical handbook for health professionals.

World Health Organization. (2023). Child maltreatment fact sheet.