Metacarpal and phalangeal fractures are commonly seen, and often require surgery. Although intramedullary fixation is a relatively new surgical technique, it is gaining in popularity as it allows patients to resume range of motion early in the postoperative period with excellent clinical outcomes. Compared to other operative fixation methods for metacarpal and phalangeal fractures, including closed reduction percutaneous pinning and open reduction internal fixation, less surgical dissection is required, which allows for faster recovery and decreased pain. Here we will discuss the use and advantages of minimally invasive implants in treatment of hand fractures. Other fractures in the hand and upper extremity result in a significant degree of bone and often soft tissue loss. The second part of the talk will focus on the use of vascularized bone grafts and composite flaps for reconstruction of complex defects in the hand and upper extremity.