Fractures of the radial head continue to challenge orthopaedic surgeons. Fortunately, most simple uncomplicated fractures treated non-operatively with emphasis on early motion achieve good results. Treatment of more complex fractures remains controversial, however. When simple radial head excision is contraindicated, choosing between open reduction and internal fixation and radial head replacement remains difficult. A review of the literature does not provide definite guidelines, but suggest that fracture complexity and technique are critical for success. This paper is not intended to review the treatment of radial head fractures, but rather to focus on choosing between replacement versus internal fixation when preservation of radial head mechanics is indicated.