Long bone pathological fractures very much reflect bone metastases morbidity in many types of cancer. The aim of this review is to establish a state-of-the-art of the risk assessment of long bone metastases fractures, from simple radiologic scores to more complex multidimensional bone models, in order to define new decision-making tools. However, due to increasing concern regarding the lack of accuracy, new thresholds have been defined for the identification of impending fractures that require prophylactic surgery, on the basis of axial cortical involvement and biomechanical models involving quantitative computed tomography. As the Mirels scoring system takes into account both the radiological and the clinical criteria, it has been used worldwide since the 1990s. Therefore, the main issue for tumor boards remains timely assessment of the risk of fracture, as this is a key consideration in providing preventive surgery while also avoiding overtreatment. Weakening of the bone results in pathologic fractures that not only compromise patient function but also their survival. Long bone metastases are frequently a pivotal point in the oncological history of patients.
