I think elegance and realism are probably incompatible. It's hard to deal with the fact that one person can be mortally wounded yet have enough strength to fight on, while another person can be bonked on the head and rendered unconscious without really being wounded at all. Realism is mechanically tedious.
I agree that it is difficult. And I fully agree that it is tedious. But, neither of those things make it less elegant.
GURPS is a good example of this. This is a system the relies heavily on similutionist gaming. GURPS strives for mechanics which offer realistic results to actions. Thus, when you get whacked with a sword, or shot, or whatever, you have to determine a lot more details than just marking off some hit points.
And, by and large, it succeeds at doing so. I think most people who have played GURPS would say that GURPS strives for realism in its settings. Now, it may never acheive that goal, but, it certainly tries.
Does that make it less elegant than DnD? I don't believe so. The comparison falls apart because the goals are so different. If I want to hit someone in the head in DnD, I can't. Plain and simple. I remember a comic in Dragon from years back about an execution of some big nasty barbarian. He's standing there pincussioned with arrows and a clerk on the side is marking off hit points.
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(Granted, in 3e, with the CDG rules, it might be different, but, then again, with a high level barbarian, maybe not)
In Gurps, I consult a few tables and hit someone in the head with all the effects that come from that.
Elegance in game rules will always be based on the goal of the game. If the goal is very fast play with heavy reliance on DM interpretation, then the rules should reflect that goal - thus we have games like the aforementioned RISUS. If we want a more tactical game but not entirely simulationist, we get DnD. If we want the game to emulate realism to highest degree possible in a game, then the rules should reflect that.
It's when the rules don't reflect the game goals that they become inellegant. Multiclassing in DnD is a good example in my mind. One of the goals in DnD is Any Concept is Playable. But, this falls apart without either bridge PrC's or specific feats when applied to caster classes.
IMO, the multiclass rules work, but are inellegant because they don't work in fairly broad ways.
Polymorph and it's ilk are another example of inellegance. Rules that just explode the complexity of the game without adding a whole lot to the game itself.