The majority of simple fractures of the radial head are stable, even when displaced 2 mm. Articular fragmentation and comminution can be seen in stable fracture patterns and are not absolute indications for operative treatment. Preservation and/or restoration of radiocapitellar contact is critical to coronal plane and longitudinal stability of the elbow and forearm. Partial and complete articular fractures of the radial head should be differentiated. Important fracture characteristics impacting treatment include fragment number, fragment size (percentage of articular disc), fragment comminution, fragment stability, displacement and corresponding block to motion, osteopenia, articular impaction, radiocapitellar malalignment, and radial neck and metaphyseal comminution and/or bone loss. Open reduction and internal fixation of displaced radial head fractures should only be attempted when anatomic reduction, restoration of articular congruity, and initiation of early motion can be achieved. If these goals are not obtainable, open reduction and internal fixation may lead to early fixation failure, nonunion, and loss of elbow and forearm motion and stability. Radial head replacement is preferred for displaced radial head fractures with more than three fragments, unstable partial articular fractures in which stable fixation cannot be achieved, and fractures occurring in association with complex elbow injury patterns if stable fixation cannot be ensured.