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Abstract This study proves that the goal of treatment of scaphoid nonunion should be consolidation of the fracture in anatomic alignment. Advanced imaging, including CT and MRI, aids in the evaluation of scaphoid alignment, bone loss, scaphoid humpback deformity, carpal collapse, and osteonecrosis. Generally, scaphoid nonunions with severe collapse and humpback deformity must be approached volarly with interposition of an intercalary bone graft and internal fixation. A dorsal approach to proximal scaphoid nonunions allows immediate access for removing the necrotic bone from small proximal pole nonunions and internal fixation. Vascularized bone graft is recommended to manage scaphoid nonunions with osteonecrosis |