Femoral neck fractures in elderly patients are intracapsular proximal femur fractures with increasing incidence due to the ageing population, and are associated with substantial mortality and morbidity. The fragile blood supply of the femoral head causes these fractures highly susceptible to nonunion and avascular necrosis. Treatment decisions should therefore be individualized based on the degree of fracture displacement and the patient’s biological age, bone quality, and functional status. In nondisplaced fractures (Garden types I-II), osteosynthesis is preferred in patients under 80 years of age with a posterior tilt below 20°, whereas arthroplasty should be considered in older patients or in those with higher posterior tilt. In displaced fractures (Garden types III-IV), arthroplasty is the standard approach. Hemiarthroplasty is adequate for most patients, while total hip arthroplasty may yield superior functional outcomes in selected, biologically younger and more active individuals. Unless specifically contraindicated, a cemented femoral stem should be preferred. The success of surgical treatment depends on minimizing time to surgery, effective pain control, delirium prevention, early mobilization, thromboprophylaxis, and the implementation of an orthogeriatric co-management model. Every elderly femoral neck fracture should also be regarded as an opportunity for secondary fracture prevention through the initiation of osteoporosis treatment.