Femoral neck fractures in the geriatric patient continue to represent a therapeutic challenge. Despite advances in surgical techniques and medical care, the risk of nonunion and osteonecrosis after fixation have not changed appreciably in the last 50 years. Considerable debate continues to occur with respect to the relative merits of internal fixation versus arthroplasty. The relative benefits and complications of unipolar and bipolar hemiarthroplasty, as well as total hip replacement, continue to be poorly understood. The next decade will bring advances in the prevention and treatment of osteoporosis that may finally decrease the incidence of these fractures. Advances in the use of bone graft substitutes may finally improve the outcome of internal fixation.