Adam Pasquinelly, MD
May 1, 2026
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Match day has come and gone, and now you’re well into the process of planning a transition to residency. You might be a bit nervous about starting in your new role, and feeling some anxiety about your readiness to take on the challenge of orthopaedic surgery training. How will you play the part of a surgeon when you had limited autonomy during medical school? What if people think you aren’t skilled enough in the OR? These are valid thoughts, and you would be far from the first new resident to feel this way. Residency is the place to build and refine these surgical skills through experience, and if you want a head start on becoming a smooth operator, intern year is the right time to get to work! This isn’t a mandatory checklist; everyone progresses at their own pace, so do your best and don’t be daunted. Here are 10 surgical skills to try to master by the start of your PGY-2 year, giving you a strong foundation on which to build up your repertoire in the OR.
1Preoperative Planning
While not a ‘surgical skill’ in the strict sense, this is one of the main abilities you will be expected to develop throughout residency, and is arguably the most important part of every surgical case. Many attendings will assess your preoperative plan at the start of a case to determine how prepared you are for that surgery, and adjust your role in that case accordingly.
- How to practice – After a common case, write down everything you remember between the patient rolling into the OR and the first incision. This includes which bed is used, patient position, adjuncts used for positioning (foam ramps, bumps, etc), starting drapes and pre-scrub, and anything else. Once you have a good idea of these steps and you’ve seen them repeated several times, start to make preoperative plans for your upcoming cases, starting with these steps. Next, write down everything you see during approaches, identify common themes, and incorporate that into your plan. Continue this process until you feel like you can walk through that common case, from OR entry to exit.
2Draping
In most academic centers, residents will help out with the prepping and draping of surgical patients, especially when surgeons are managing multiple rooms. Learning to drape well will keep your day running smoothly, and will also show your attending that you have prepped a bit for this case. Draping incorrectly or not respecting sterility will quickly get you barred from doing the case, so pay attention!
- How to practice – Get together with your co-residents and a senior, ask for old or expired drapes from the OR staff, and practice draping on each other for different types of common procedures. Each time you visit the OR to staff a consult during a case, take a couple seconds to check what surgery is going on and how the drapes are applied.
3Retracting
While you likely gained significant experience with this during medical school, you will see that there is still a lot to learn. As you see more cases from a lead surgeon’s perspective, you will have better intuition of when and how to move retractors, and how to best direct your assistants.
- How to practice – When you are in anatomy lab, try to get access to various retractors, and practice holding exposure for an approach. Notice that different retractors have different mechanisms of action; Hohmann retractors generally require a lever action as well as a downward push to ensure the tip stays in contact with the surface you are
retracting from, and Army-Navy retractors generally require a bit of toe-in instead of straight pull to make sure you don’t slip.
4Using Ring Handled Instruments
You have probably been working on palming a needle driver, which is a great start for another frequently used but tricky instrument – the reduction clamp. Even before you are attempting reductions yourself, you will probably be asked to release or move a clamp when the attending’s hands are holding a tenuous position. Proficiency can prevent unnecessary struggle during these moments.
- How to practice – Repetition! Hold some clamps, learn how they work, and practice releasing the catch mechanism with one hand. Practice reducing sawbone fractures as often as you can.
5Cautery dissection
Unless you had a very unique medical school experience, you likely haven’t used electrocautery (Bovie). Using electrocautery for dissection or hemostasis can be intimidating early on, so it is helpful to at least know how to hold the instrument so you can focus on the surgery itself.
- How to practice – Electrocautery works on cadaver tissue, so see if your lab can accommodate a cautery setup and practice in a low-stress environment. IYou can also ask for a clean discarded or expired cautery pack and just practice holding and using both buttons smoothly, even if it’s not hooked up to anything.
6Trigger control
Using power tools in surgery is awesome. Drills, saws, and power drivers are staples in orthopaedic procedures, and you are very likely to be handed a drill in the OR early in your intern year. You can shine early by having good control over your speed.
- How to practice – Get a cheap drill or power driver from a tool store. First go full speed, and then as slow as the drill will go, and then go as close to half speed as you can. Hold this for a few seconds, then try 50% slower than that, hold, and repeat. Try to obtain and hold as many incremental speeds as you can, and then try to reach them again but out of order. Use the pitch of the drill sounds to gauge success.
7Steadiness in 3D space
This is an important surgical skill that directly impacts how well you can do almost anything in the OR, including several skills listed above. Holding your position in space is essential for finding a nail start point, imparting the desired version of a broach when prepping the femur in a total hip, and ensuring your lag screw finds the drill hole in the far cortex.
- How to practice – Your program may already have K-wire or drill trajectory trainers, and you can also easily make one with a PVC pipe and a marker, making two dots on opposite sides of the pipe and connecting them with a drill. To add difficulty, fill the pipe with a pool noodle or florist’s foam to make it hard to redirect the drill. Set your trajectory while looking at the far side dot, pause for 30 seconds to practice hand steadiness in space, then advance your drill without looking at the dot again.
8Understanding Your X-Rays
Intraoperative fluoroscopy is integral to orthopaedic surgery, and can also be one of the toughest things to really nail down in your training. Subtle C-arm or instrument adjustments drastically alter the projected image and its clinical utility. Gaining an understanding of why x-ray might be used in a specific circumstance (e.g. a perfect view down a joint space to make sure screw tips aren’t intraarticular) can help you gain more insight from each case you observe.
- How to practice – Repetition! Search for websites with demo x-rays as well as fluoroscopy training modules and videos that can supplement understanding. If you have access, put on some lead and practice C-arm views with sawbone models.
9Deep Closure
In contrast to medical school, you will now also be closing the deep intervals of the surgical approach. Closing well is a great way to gain trust with your attendings, especially since errors may only become apparent at the two-week follow-up.
- How to practice – Suture trainers won’t help much with deep closure, so watch closely when attendings and PAs are closing. Stay after cadaver labs to practice closing, especially for hip and knee exposures where good deep closure is essential.
10 Superficial Closure
You’re definitely familiar with subcutaneous and skin closure at this point, and you also now have a personal interest in making a clean and watertight closure because you (or the on-call resident) will be the first point of contact for wound complications and saturated dressings.
- How to practice – Use suture pad trainers, pieces of meat from a butcher shop, and cadavers. Practice grabbing only the subcutaneous portion of the skin edges and avoid ever pinching the epidermis; your older patients with thin wispy skin will appreciate the effort!
DISCLOSURES: Dr. Pasquinelly This individual reported nothing to disclose.
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