Background <p>Intra-articular distal humerus fractures (DHF) carry a technical challenge for orthopedic surgeons, owing to the complex geometry of the distal humerus. Surgical management is the standard of care for these fractures. The aim of this network meta-analysis was to compare the clinical outcomes of the different open reduction and internal fixation (ORIF) and arthroplasty techniques for the management of intra-articular DHFs.</p> Methods <p>The databases Medline, Embase, and CENTRAL were searched for relevant studies. Randomized controlled trials (RCTs) were included if they matched the following criteria: skeletally mature adult patients, including elderly and young adults, with type C bicolumnar intra-articular DHF according to the AO classification, and performed a pairwise comparison between any of the following interventions: (1) ORIF with perpendicular double plating; (2) ORIF with parallel double plating; (3) ORIF with Y-shaped double plating); (4) EHA; (5) TEA. The outcomes of interest in this study were arc of motion, Mayo Elbow Performance Score (MEPS), and adverse event rate. The network meta-analysis was performed through a Bayesian-based framework using the BUGSnet package in R software. Treatments ranking was performed through the Surface Under the Cumulative Ranking (SUCRA).</p> Results <p>Ten RCTs were found eligible for inclusion, representing 357 patients. The different surgical techniques showed similar results with respect to the arc of motion, and ORIF with parallel plating had the best rank (SUCRA = 83.56). ORIF techniques showed a significantly better MEPS score compared to arthroplasty, and ORIF with parallel plating had the best rank (SUCRA = 85.63). The adverse event rate was similar across the different surgical interventions and EHA showed the best rank (SUCRA = 67.53).</p> Conclusion <p>No substantial difference was found between the different surgical techniques with respect to the clinical outcomes and adverse events. ORIF with parallel plating showed the highest ranking with respect to arc of motion, MEPS score, and reducing risk of HO but without statistical significance. The choice of the appropriate surgical technique should be tailored to each patient under the consideration of the age, fracture pattern, and salvageability. </p> Trial registration <p>PROSPERO registration number: CRD42024603193</p>