Metastatic bone disease compromises the structural integrity of bone and puts patients at risk of pathologic fractures. It is generally accepted, for multiple reasons, that prophylactic stabilization of impending pathologic fractures is preferred to management of complete pathologic fractures. As such, identifying an impending pathologic fracture is important to avoid unnecessary morbidity and disruption to ongoing oncologic care; however, risk assessment is multifactorial and challenging, and, although sensitive prediction tools exist, they are particularly limited by low specificity. Treatment typically consists of a combination of operative and nonoperative strategies, including minimally invasive and open surgery, radiation therapy (RT), systemic anticancer and bone-targeted agents (BTAs), and pain regimens. Treatment decisions are multidisciplinary and hinge on the extent of involvement, primary tumor histology, and location, along with patient prognosis and goals of care.