Femoral neck fractures account for half of all hip fractures with a rapidly increasing incidence. Since they are associated with high mortality, decrease in quality of life, and high total costs, much research on the optimal treatment of these fractures has been undertaken. In this article, we provide a summary of the available evidence comparing open reduction and internal fixation and arthroplasty. We focus on the treatment of displaced femoral neck fractures in active, healthy elderly patients. Additionally, we discuss treatment options for patients with undisplaced femoral neck fractures, younger patients, and patients with cognitive impairments. Furthermore, we present cost-effectiveness analyses on the treatment of these fractures, comparing both costs and patient benefits between internal fixation and different arthroplasty approaches.