Vascularized bone grafts offer the ability to transfer bone with viable osteoclasts and osteoblasts with a preserved circulation. The resultant primary bone healing without creeping substitution through necrotic bone is an attractive alternative to conventional bone grafting in aiding or accelerating healing, replacing deficient bone, and revascularizing necrotic bone. Recent advances in the anatomy and physiology of vascularized bone grafts have increased the understanding and ability to apply them to various of carpal maladies. This article focuses on the principles, anatomy, application, and experimental and clinical studies of vascularized bone grafts for the treatment of scaphoid nonunions and Kienböck's disease.