Fractures of the distal humerus in adults have traditionally presented a treatment challenge for the orthopedic surgeon. The combination of anatomic complexity, multifragmentary comminution, and a short distal segment, often in the setting of osteoporotic bone, renders these fractures difficult to treat successfully and often make a full restoration of function uncertain. Multiple methods of treatment for these fractures have been described, including bracing, internal fixation, hemiarthroplasty, and total elbow arthroplasty. This article reviews the epidemiology and classification of these injuries and the numerous described fixation and arthroplasty techniques. The current treatment algorithm and authors' preferred method of internal fixation are also illustrated. Additionally, the treatment of these injuries in the elderly population and the complications of surgical treatment are reviewed.