Until recently, there had been few advances in the science of predicting fracture risk in the setting of metastatic cancer from the early days of orthopedic oncology. Numerous rules based on clinical and plain film radiographic criteria evolved into Mirels scoring and Carnesale’s “conventional” definition, as well as its variation, the L-cort >30 mm rule, and then nothing new appeared for many years. Within the last few years, however, much has been published regarding CT-based techniques, particularly CT-based structural rigidity analysis (CTRA). Other techniques such as finite element modeling (FEM) and fludeoxyglucose positron emission tomography/computerized tomography (FDG PET/CT) continue to evolve. In addition, techniques that combine imaging with demographic and oncologic characteristics, similar to what has been done to predict fractures in osteoporosis using the World Health Organization’s (WHO) Fracture Risk Assessment Tool (FRAX), merit consideration. At this point, albeit improved from 30 years ago, precise, practical, and widely available prediction of impending fractures in patients with metastatic lesions remains elusive and warrants further prospective evaluation. In addition, although it would seem intuitively obvious that preventing a pathologic fracture is important, literature supporting this is lacking, and evaluation of the clinical and financial benefit of such preventative testing requires more investigation.