Purpose <p>There is still no consensus about treatment distal humerus fractures (DHF) in elderly patients. This retrospective study compare the mid-term outcomes of intraarticular DHF in patients over 60 years of age treated with open reduction and internal fixation (ORIF) and total elbow arthroplasty (TEA).</p> Methods <p>We have evaluated 64 patients who have undergone treatment for intra-articular DHF (AO types C, 31 TEA vs. 33 ORIF). Our assessment included: range of motion, Mayo Elbow Performance Score (MEPS), Quick-DASH score and numeric pain score (NRS). Rate of complications and reoperations were examined. All patients were followed for a minimum of three years.</p> Results <p>At the final follow-up, mean flexion-extension ROM was 119,9° +/-27.8° vs 79.3° +/-23.8° for TEA group and ORIF group respectively and prono-supination ROM was 167.8°+/-16.2° vs 150.2°+/-36.9°. Mean MEPS was 82.6+/-12.6 vs 70.3+/-13.6 for TEA and ORIF respectively. Mean DASH score was lower in the TEA group, 22.7+/-15.5 vs 37.6+/-21.2. The number and rate of complications was higher in the ORIF group. Reoperation rates were 30.3% and 19.35% for ORIF and TEA respectively.</p> Conclusions <p>TEA could lead to a satisfying functional outcomes with more predictable results and less complication then ORIF for DHF in the elderly.</p>