Metastasis to bone is the most common cause of destructive lesions to the skeleton in adults. Advances in chemotherapy, radiation therapy, and reconstructive techniques have improved the treatment options for patients with metastatic bone disease. Surgical treatment is often required for pathological and impending fractures of the extremities and periacetabular areas of the pelvis. Treatment can be challenging and depends on a variety of factors including the type of primary malignancy, anatomic site, extent of bony involvement, presence or absence of fracture, concurrent medical conditions, and life expectancy. The treating clinician must be familiar with the indications for operative intervention, site-specific approaches to surgical fixation and reconstruction, and nonsurgical treatment options for metastatic lesions. The authors outline their preferred approach to the management of bone metastases in the extremities and pelvis.