Treatment of a large articular cartilage defect in the distal radius poses a significant challenge to hand surgeons. To reduce the development of secondary degenerative arthritis, restoration of the articular surface is preferable. Pedicle pisiform transfer has been reported as a useful treatment option for Kienbock's disease. We describe a surgical technique involving vascularized pisiform transfer for large cartilage defects after intra-articular distal radius fractures and highlight the vascular supply of the pisiform. (J Hand Surg Am. 2015;40(10):2075-2080. Copyright (C) 2015 by the American Society for Surgery of the Hand. All rights reserved.)