: The incidence of hip fractures in patients with a history of cancer is expected to increase, whether the fracture is pathologic or not. This study sought to answer two decision points: (1) What is the appropriate imaging modality to determine if the fracture is pathologic? (2) Is osteosynthesis (OS) an appropriate technique in the management of femoral neck fractures in patients with a history of cancer? We did a retrospective review of patients presenting with femoral neck fractures that underwent OS or hemiarthroplasty (HA) at a single oncologic referral center. 127 patients were identified, 109 underwent HA and 18 underwent OS. Comparison of the imaging to the histologic analysis was performed to determine the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the various imaging modalities. Analysis of radiographic imaging demonstrated the addition of advanced imaging improved the accuracy, sensitivity, specificity, PPV, and NPV compared to radiographs alone. Both HA and OS offered durable reconstructive options. Radiographs without advanced imaging for comparison are incorrect 26% of the time; advanced imaging improves the accuracy. Osteosynthesis is a durable reconstructive option in patients with a history of cancer without an underlying pathologic fracture.