Management of femoral neck fractures continues to center on a critical decision: internal fixation or joint replacement. Treatment selection depends on factors such as patient age, fracture displacement, bone quality, functional demands, and overall health status. Internal fixation preserves the native hip and may be preferred in younger patients, but it carries risks of nonunion and avascular necrosis. In contrast, hemiarthroplasty or total hip arthroplasty can provide more reliable pain relief and earlier mobilization in older adults, particularly for displaced fractures. Emerging evidence increasingly supports individualized treatment strategies that balance fracture healing potential with long-term function and complication risk, emphasizing patient-specific decision-making rather than a universal approach.