In the physiologically compromised elderly patient with an acetabular fracture, nonoperative treatment is associated with functional outcomes (as indicated by the Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] scores) similar to those seen in healthier patients who undergo open reduction and internal fixation, with similar mortality and lesser need for late conversion to total hip arthroplasty. Open reduction and internal fixation of displaced acetabular fractures in patients older than 60 years of age is an excellent option provided that the patient does not have risk factors for failure such as acetabular dome (roof) impaction, femoral-head impaction, or a posterior-wall component. Specific techniques to treat quadrilateral plate involvement and dome impaction are necessary to ensure a durable result. More limited operative approaches and percutaneous fixation have a role in this patient population to minimize the morbidity associated with more extensive exposures. The clinical and radiographic outcome of posterior-wall acetabular fractures that have associated comminution, marginal impaction, and/ or femoral-head impaction fractures is predictably poor, with rapid onset of posttraumatic arthritis. Immediate total hip arthroplasty in this population is simple and has outcomes equivalent to those of total hip arthroplasty for coxarthrosis. Total hip arthroplasty should be considered for patients who are $60 years of age and have posterior-wall acetabular fractures and perhaps even in younger patients when there are multiple injury factors that predict a poor outcome. The published clinical results of the use of acetabular reconstruction rings, bone graft, and revision arthroplasty techniques appear to be similar to the results of combined internal fixation and insertion of uncemented acetabular components. Surgeons should choose an operative plan that is appropriate to their particular training and skills, the patient's particular fracture, and hospital resources.