Although less prevalent than hip and knee osteoarthritis, elbow osteoarthritis has a substantial impact on upper extremity function and presents unique clinical challenges. The condition is frequently post-traumatic and may affect young, active individuals, whereas primary elbow osteoarthritis is typically characterized by osteophyte-dominant degeneration related to repetitive mechanical loading. Patients commonly present with pain, progressive stiffness, mechanical impingement, and functional limitation. The principal challenge in management arises from the heterogeneity of clinical phenotypes and the wide variability in patient expectations. Contemporary understanding supports a phenotype-based evaluation rather than a purely etiological classification and highlights the critical role of imaging in guiding treatment decisions. Joint-preserving procedures, performed either arthroscopically or through open techniques, are preferred in patients with preserved joint space and osteophyte-dominant pathology, whereas advanced stages characterized by diffuse cartilage loss often require arthroplasty or salvage procedures. This review provides a comprehensive overview of the epidemiology, biomechanics, clinical phenotypes, and current treatment strategies for elbow osteoarthritis and proposes an algorithmic framework to assist clinical decision-making.