Objectives: A neglected nonunion of the scaphoid of the wrist causes secondary changes limiting joint function. It is also imposing further difficulties in establishing bone union. A vascularized bone graft from the distal radius (dorsal or palmar) has been prospectively utilized in 40 patients with 3.7 years old (range: 1-17 years) nonunited scaphoid fractures and 2 patients with enchondroma. Methods: Forty patients were male and 2 female with age range from 19 to 52 years. The injury affected the dominant hand in 34 of them. Six of the patients had an unsuccessful previous surgical procedure and scapho-styloid arthritis was present at the time of the operation in 11 patients. Preoperative evaluation included x-ray examination of both wrists and additional imaging evaluation (tomograms-CT-MRI) in selected cases, as well as assessment of pain, range of motion and grip strength. A dorsal radial vascularized bone graft was used in 38 patients, and a palmar graft in 4. The procedure was carried out under axillary block anesthesia in 34 cases. Through a dorsal or palmar approach the respective branch of the radial artery (recurrent intercompartmental or pronator quadratus branch) was identified and a 12 x 10 mm rectangle cortico-cancellous graft of at least 10 mm in depth was elevated with the vascular bundle protected by a 3 mm wide strip of fascia and periosteum. The pathologic tissue from the scaphoid nonunion was excised and after curettage and tourniquet release, punctuate bleeding was assessed - this was absent in the proximal segment in 13 cases. The length of the (proximal and distal) scaphoid segments was subtracted from the length of the normal scaphoid and determined the dimensions of the graft. The graft was interposed to the post-curettage defect (intercallary graft) and was secured with 2 KW. A long arm cast was applied for 6 weeks and after removal of the KW, a short arm cast was applied for 1-5 more weeks. In 7 of the 11 cases with scapho-styloid arthritis, a closed wedge osteotomy of the distal radius was carried out at the same operation. Results: Follow-up time ranged from 12 to 86 months. Union and graft incorporation were assessed on x-rays in the majority of patients and on CT scans in 5 patients. Union was accomplished in all cases in a time period of 7-11 weeks. The length of the scaphoid was reconstructed in a range from 76-93% (average: 85%) of the normal side. Wrist flexion-extension improved from 63o preoperatively to 86o postoperatively and radial-ulnar deviation from 17o to 29o. Grip strength improved from 67% to 88% of the contralateral site. Complete absence of pain in any kind of activity was noted in 31 patients. Despite fracture healing, in the patients with arthritic changes pain with strenuous use of the hand was not completely eliminated postoperatively. All patients returned to their previous occupation in a period of 4-6 months and were satisfied from the general improvement of function of their wrist. Conclusions: The single surgical approach, the possibility to complete the procedure under regional anesthesia, the ease in the dissection of the graft with a constant vascular pattern and avoidance of anastomosis, in addition to the very high rate of successful healing, are certain advantages of the technique employed in this series. The findings of our series demonstrate the efficacy of the vascularized pedicular graft from the adjacent radius to establish union and correct major alignment defects in neglected scaphoid fractures. In cases of degenerative changes of the joint architecture the final functional outcome was compromised.