Acetabular fractures are becoming more common, especially in the elderly population. Standard goals of management include restoring stability and articular congruity to the hip joint in an effort to minimize the risk of posttraumatic arthritis. This is most commonly achieved through open reduction and internal fixation, from which outcomes are generally positive. However, several preoperative risk factors have been identified that correlate with poor outcomes, such as severe acetabular impaction, femoral-sided lesions, and older age. Furthermore, goals of management in the increasingly encountered elderly acetabular fracture may predominantly consist of postoperative mobilization and minimizing revision surgery. In the select patient with identifiable risk factors, acute total hip arthroplasty with or without concurrent fracture fixation may be able to improve outcomes. Specifically, acute total hip arthroplasty appears to reduce the risk of revision surgery in comparison to fracture fixation alone and may improve complication profiles in comparison to conversion arthroplasty after failed fixation, albeit at the expense of an increased surgical insult at the initial surgery. However, given the heterogeneity and short-term nature of the available data, more robust and long-term data will be required before definitive conclusions can be drawn.