BACKGROUND: Fixation of radial head fractures with neck involvement presents challenges. It remains unclear whether the outcomes of head-to-neck screw fixation are similar to those of arthroplasty in this scenario. We conducted a retrospective cohort study to evaluate the clinical outcomes of these two methods for treating such fractures. METHODS: Demographic data, fracture type, number of fragments, and concomitant injuries were recorded. Range of motion, Visual Analogue Scale for pain, Mayo Elbow Performance Score, and Quick-Disabilities of the Arm, Shoulder, and Hand at three-year follow-up, complications, and reintervention were compared. RESULTS: A total of 14 patients underwent fixation with head-to-neck screws, and 15 an arthroplasty. Baseline characteristics between groups were similar ( DISCUSSION: Head-to-neck screw fixation and radial head arthroplasty result in similar postoperative outcomes for low-comminuted radial head fractures with neck involvement.