Question
A 66 year old man has back pain, fatigue and anaemia. A skeletal survey is performed.
- What is the diagnosis and how is it confirmed?
- Why is a bone scan unhelpful?
- What is the orthopaedic role in management?
Answer
Diagnosis
- Multiple myeloma with punched out lytic lesions
- CRAB features are hypercalcaemia, renal impairment, anaemia and bone lesions
- Serum and urine protein electrophoresis and serum free light chains
- Bone marrow biopsy showing clonal plasma cells
- Whole body low dose CT, MRI or PET CT for staging
Bone scan
- Lesions are purely lytic with little osteoblastic response, so they are often cold
Management
- Haematology led chemotherapy with bisphosphonates or denosumab
- Radiotherapy for painful lesions
- Prophylactic fixation of impending fractures guided by the Mirels score
- Vertebral augmentation for painful compression fractures
- Solitary plasmacytoma is treated with radiotherapy
- Biopsy a solitary lytic lesion before fixation if the diagnosis is unproven
Related pages
Author Contributions
Orthofracs team
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.