Surgeons can directly impact the success of treating patients with scaphoid nonunion by separating waist nonunions from proximal pole nonunions. Most proximal pole nonunions have osteonecrosis, and in such situations a dorsal approach combined with vascularized bone grafting provides a reasonable treatment option. For patients with scaphoid waist nonunion, the surgeon must determine whether or not there is osteonecrosis and/or a collapse deformity. In the rare event that no collapse is present, the nonunion can be treated using a volar approach or dorsal approach with or without a vascularized bone graft, depending on the presence of osteonecrosis. If collapse is present, then use of a volar approach is necessary, combined with a volar rotation of a vascularized bone graft supplied by the 1,2- intercompartmental supraretinacular artery if osteonecrosis is present.