Primary total elbow arthroplasty is a treatment option for elderly patients with osteopenic bone, increased comminution, and articular fragmentation. Recently, there has been a renewed interest in distal humerus hemiarthroplasty for the treatment of distal humerus fractures, including coronal shear fractures of the capitellum and trochlea. This article focuses on the evaluation and management of distal humerus fractures with prosthetic replacement.