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Management of distal humerus fractures continues to challenge orthopaedic surgeons. The unique and complex anatomy of the distal humerus, involving the ulnohumeral and radiocapitellar joints, makes anatomic reduction difficult and hardware placement challenging. However, long-term results of well-performed open reduction and internal fixation demonstrate satisfactory outcomes in most patients. Osteoporosis in the elderly population often leads to severe comminution, which may render open reduction and internal fixation impossible. Total elbow arthroplasty in the elderly has become a viable option, with excellent results in the properly selected patient who understands the lifetime limitations of this option. Distal humeral replacement is a new and potentially exciting option but it is currently not approved by the US Food and Drug Administration and has no long-term follow-up to support its use.