The first 3 months of life are sometimes referred to as the “fourth trimester,” in reference to the dramatic transition, the newborn must make from life inside the uterus to the outside world. During this time period, the infant can already turn toward a parent’s voice and attend to a human face. But they still have open fontanelles, poor head control, and poor ability to regulate their body temperature. It can be intimidating for the surgeon who does not see infants regularly to handle and examine these fragile little humans under the watchful eye of their anxious (and sleep-deprived) parents. The exam should begin with the infant swaddled, either in their parent’s arms or on the exam table. The area of interest can then be exposed for the exam, while the remainder of the infant remains covered and warm. Provocative maneuvers and anything that might cause pain should be reserved for the end of the examination. Passive range of motion testing can be a provocative maneuver in an infant, as they generally do not like for an extremity to be held or confined, so this testing should be saved for the end as well.

Observing active use of the upper extremities can be difficult in newborns. They will tend to hold the upper extremities with the arms adducted, elbows flexed, forearms pronated, and fists clenched. Very young infants will not yet reach for toys and rattles. Instead, active motion can be elicited by tickling or stroking the area of interest (such as the back of the hand to elicit finger extension). Infant reflexes can also be used to the examiner’s advantage (Table 2).

Infants at this age should be able to engage much more readily with their environment than the newborn. Late infancy is a time of rapid development in both gross and fine motor skills. Although each child’s development may progress differently, there are general milestones that can be expected:

Specific to hand development, infants progress through a standard pattern of grasp development during this time (Case-Smith 1995). At 5–6 months, an instinctive palmar grasp develops, using the entire hand as a unit without independent use of the digits or any meaningful use of the thumb and without regard for visual input (Fig. 1). The infant typically secures the object and then adjusts their grasp accordingly. This is a transitional behavior between the grasp reflex (see Table 2) and more mature grasp patterns. By 7–8 months, the infant develops a more purposeful grasp, most commonly a raking (or palmar) grasp, in which they can stabilize the object using the fingers themselves, rather than by holding the fingers against the palm (Fig. 2). The 7-month-old typically approaches and manipulates an object with both hands, grasping and inspecting it before bringing it to their mouth. At 9–12 months, the child begins to use the thumb independently as the tip pinch (pincer grasp) develops. In the pincer grasp, the thumb and index finger are opposed pad to pad to hold an object (Fig. 3).

Toys can be a useful distraction device at this age and can also assist in the examination. We often allow a baby to “warm up” to the office setting and the examiner by providing a few toys for them to play with independently. This independent play allows for careful inspection of hand function, and the examiner can gradually join in with the play to encourage specific hand functions. Similarly, once infants begin to eat finger foods, around 6 months of age, many parents will have snacks with them which can be a great adjunct to the examination. Stranger anxiety presents at different ages and to a different extent in each child but generally peaks between 6 and 12 months of age. For this reason, more focused or difficult portions of the exam of older infants are often better accomplished with the child in the parent’s lap.

Growth and development continue rapidly during this time period. By 18 months, the child should be able to walk independently, say several intelligible words, and feed themselves with a spoon. A 2-year-old can run, speak in 2–3-word sentences, manipulate large buttons and zippers, and scribble with a crayon. A 3-year-old can speak in full sentences, throw and catch a ball, and hold a crayon with a tripod grip. By 5 years old, language is more complex, as are fine motor skills (such as stringing small beads) and the child’s hand dominance is generally established.

Toddlers become accustomed to visiting the pediatrician for immunizations, so during this time period they may begin to associate the doctor’s office and all the white coats with getting “a shot.” They may start to be intimidated by large groups of people, such as the myriad of doctors and trainees at a teaching institution. In addition, toddlers are increasingly difficult to distract and win over with a simple toy, so distraction devices that worked in the past for the infant examination will not always continue to work. Although some parents may request that the doctor remove the white coat, this rarely will actually make a difference in the toddler’s perception of the exam, and appropriate dress is really at the discretion of the examiner.

Toddlerhood is all about increasing self-awareness and increasing independence. This can be used to the examiner’s advantage by giving the toddler choices throughout the examination. A classic mistake is to ask a toddler “Can I see your hand?” After this question, any self-respecting 2-year-old will shout “No!” and hide that hand from view for the rest of the doctor’s visit. Instead, the 2-year-old should be asked “Do you want me to look at this hand first, or the other one?” This and other choices such as “Do you want to sit on your mom’s lap or on the table?” can help the toddler feel in control of the situation while you can proceed with the necessary parts of the examination.

Even with all of the above, some children of this age will be simply too difficult to examine properly on a given day. If this is the case, it is best to do as much of the examination as possible, then reassess the situation. At times, a short break from the exam is all that is needed. At other times, you will need to document thoroughly what you were or were not able to examine and bring the child back for a repeat examination on another day.

In general, school-aged children are much easier to examine than children under 5 years of age. The examination can begin to model a more adult pattern. For example, children can follow instructions so that things like motor strength can now be directly examined. However, children at this age often require explanations of the various components of the examination. To use motor strength testing as an example, most adults will readily comply if you ask them to “bend your elbow and don’t let me straighten it.” While school-aged children can follow these instructions, the examiner needs to slow down and explain tests more completely. For more complex tests, demonstrating with a parent first can help. For example, you may say something like “Now I need to see how strong you are. Can you bend your elbow? Now hold it bent as strong as you can and don’t let me straighten it out.”

Modesty also develops during the late elementary school and middle school years. Things that adults take for granted, such as men removing their shirts for a shoulder exam, are often much more sensitive concepts for children of this age. It is common for a 10-year-old boy to not want to take off his shirt for doctors to examine him. If the child’s chest and shoulders need to be visible for the upper extremity exam, the child should be given the opportunity to change into a gown while the examiner waits outside the room. During the exam, only the necessary body part should be exposed from the gown.

During this time period, children’s developmental skills are much like adults, but their social and cognitive skills are still maturing. Modesty remains an issue and should be addressed as above. In addition, there may be certain parts of the examination or interview that are better addressed without the parents in the room. For example, a teenage boy presenting with swelling and pain over the metacarpophalangeal joint may be reluctant to admit in front of his parents that his symptoms began after punching someone in the teeth, information which is vital to the correct diagnosis and management of his likely joint infection.

The examination can generally proceed as for adults. However, teenagers are still less accustomed to the doctor’s office than are adults, so each part of the examination should be explained, and any tests that may elicit pain should be discussed beforehand.