Femoral neck fractures (FNFs) remain "the unsolved fracture" and optimal management is still controversial. The outcomes of hemiarthroplasty (HA) and total hip arthroplasty (THA) in the treatment of FNFs are inconsistent. As demand for management of FNFs continues to grow globally, evaluation of the appropriateness of treatment remains essential, particularly in resource-constrained settings. We conducted a retrospective chart review of all patients presenting with isolated low energy intracapsular FNFs to an orthopaedic academic unit in Sub-Saharan Africa from January 2016 to April 2019. The decision regarding HA or THA was largely based upon the Sernbo score and ASA classification. The majority of patients with a Sernbo score of ≥15 and ASA class III or better received THA. There were 117 patients (33 male/84 female) 72 years (33-97 years) with FNFs who underwent 56 THA and 61 HA between January 2016 and April 2019. The mean Sernbo score was 15.99 overall (range 8-20) and was 18.95 (11-20) for THA patients compared to 14.46 (8-20) for HA patients (p = 0.042). Time taken from admission to the theatre was 8-19 days (1-22) and 7-61 days (2-31) for HA and THA respectively. The average length of stay (LOS) was 16.04 days and the main reason for same-day cancellations was the lack of post ICU/High Care beds. The 30-day mortality rates were 1.78% and 4.91% for THA and HA patients, respectively (p = 0.07). The mortality rate for patients with a Sernbo score < 15 was 15.38% overall, 8.93% for THA patients, and 21.31% for HA patients, respectively (p = 0.021). The 30-day mortality rate was comparable with published rates from developed countries. There were significant delays in time to theatre, high rates of same-day surgical cancellations, and increased LOS for both HA and THA. These factors play a cumulative role in inflating costs on a strained healthcare system in a developing country. A multidisciplinary approach including the care provision of a specialized geriatric unit is recommended. Retrospective Study, Level III evidence. © The Authors, published by EDP Sciences, 2021.