Background: The optimal management of comminuted radial head fractures (Mason Type III and IV) remains controversial, with both radial head excision and replacement being commonly performed. This study aims to compare the functional, radiological, and complication outcomes of these two surgical approaches.Methods: A prospective observational study was conducted on 76 patients with comminuted radial head fractures, with 38 undergoing radial head excision and 38 undergoing radial head replacement. Functional outcomes were assessed using the Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Visual Analog Scale (VAS) for pain. Radiological complications, including proximal radial migration and post-traumatic arthritis, were evaluated. Statistical significance was set at p<0.05.Results: Patients in the replacement group demonstrated superior functional outcomes, with significantly higher MEPS scores (88.6 vs. 75.2, p<0.001) and lower DASH scores (15.2 vs. 22.5, p<0.001) compared to the excision group. Pain scores (VAS) were also lower in the replacement group, both at rest (1.3 vs. 2.4, p=0.003) and during activity (3.2 vs. 4.8, p=0.001). Range of motion, particularly pronation-supination (82.7° vs. 70.3°, p<0.001), was significantly better with replacement.Radiologically, proximal radial migration occurred in 26.3% of excision cases versus 5.2% in replacement (p=0.015), and post-traumatic arthritis was more frequent in the excision group (21.0% vs. 7.8%, p=0.042). However, implant loosening was observed in 7.8% of the replacement group.Conclusion: Radial head replacement provides better functional recovery, improved pain relief, and reduced risk of proximal radial migration and post-traumatic arthritis compared to excision. Given its superior outcomes, replacement should be preferred in cases requiring long-term elbow stability and mobility. However, implant-related complications require further long-term evaluation.