While the majority of osseous injuries can be treated with either immobilization or surgical stabilization, there is a specific subset of injuries or conditions that require supplemental bone grafting. These include instances where there is actual bone loss (i.e., open fractures), relative bone loss (i.e., impacted distal radius fractures), or loss of sufficient bone quality (i.e., osteonecrosis). Bone resection for tumors or osteomyelitis can also result in significant actual bone loss with varying degrees of structural compromise. In order to address these insufficiencies, bone graft or bone graft substitutes are employed. Initially, simple techniques relying on cortical and cancellous autografts were employed. Today, the field has now expanded to encompass the use of allografts, synthetic ceramic-based and collagen-based matrices, demineralized bone matrix (DBM) and even vascularized bone grafts. Recently, the use of purified recombinantly manufactured human osteoinductive growth factors, known as bone morphogenetic proteins (BMPs), has also become common in the clinical realm. The science and rationale behind the utilization of the various types of bone graft and bone graft substitutes commonly employed in hand surgery will be discussed.