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Conventional bone grafts have some osteogenic potential, whereas vascularized bone grafts retain live, functional osteocytes and osteoblasts. High rates of scaphoid union have been achieved with conventional bone grafting in the absence of osteonecrosis or prior surgery. Vascularized bone grafting is valuable in the management of wrist disorders with compromised bone vascularity (eg, scaphoid nonunion with proximal pole necrosis, Preiser disease, Kienböck disease) or when previous grafting has failed. Improved understanding of the vascular anatomy of the wrist has allowed the use of an array of vascularized bone grafts that do not require microsurgical anastomosis. Successful outcome depends on careful patient selection and appropriate surgical technique.