Multiple Myeloma

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Multiple Myeloma

Multiple Myeloma
Frank J. Frassica MD
  • The most common of the plasma cell
    dyscrasias (usually with a monoclonal gammopathy) affecting the
    hematopoietic, musculoskeletal, and renal systems.
  • Classification (plasma cell dyscrasias):
    • Solitary myeloma
    • Multiple myeloma
    • Osteosclerotic myeloma
  • Synonyms: Myeloma; Plasmacytoma
Epidemiology (1)
  • Rare in patients <40 years old
  • The Male:Female ratio is ~2:1.
  • The peak age is the 6th decade of life.
~15,000 new cases (United States) annually (1)
Risk Factors
Age >40 years
The cause is unknown.
Signs and Symptoms
  • Bone pain (usually of 6 months’ duration) is the most frequent complaint at diagnosis.
  • Constitutional symptoms of weakness, lethargy, and weight loss often occur.
  • Back pain and rib pain are the 2 most frequent initial skeletal symptoms at presentation.
  • Pathologic fracture usually results in sudden-onset pain.
  • Peripheral neuropathy may be present.
  • Tendency toward bleeding and fever
  • Hypercalcemia is common.
  • Monoclonal gammopathy is revealed by serum electrophoresis and urine immunoelectrophoresis.
Physical Exam
  • Local pain and tenderness may be present.
  • A palpable mass may be found, secondary to extraosseous extension of the tumor or hemorrhage related to it.
  • Peripheral neuropathy may be detected in some patients with osteosclerotic myeloma.
  • Hypercalcemia is seen in 1/3 of cases (2).
  • Serum creatinine levels are elevated in ~50% of patients (2).
  • Anemia with hemoglobin is <12 mg/dL in 2/3 of patients (2).
  • Elevated ESRs are >50 mm/hour in 2/3 of patients (2).
  • Serum electrophoresis and immunoelectrophoresis usually reveal monoclonal gammopathy.
  • Bence Jones proteinuria is noted.
  • Hypergammaglobulinemia may manifest itself as rouleaux formation appreciable on a peripheral blood smear.
  • Radiography:
    • Plain film radiographs reveal multiple
      small, discrete, lytic lesions most commonly involving the axial
      skeleton (skull, spine, ribs).
    • The surrounding bone does not show a sclerotic reaction, nor is there a periosteal reaction.
  • Because bone scans have a high incidence of false-negative results, they are not used routinely.
    • A skeletal survey to evaluate for distant involvement often is a better study.
Pathological Findings
Monoclonal plasma cells are found in bone marrow.
Differential Diagnosis
  • Metastatic bone disease
  • Malignant lymphoma
  • Fibrosarcoma


General Measures
  • The mainstay of treatment is chemotherapy.
  • Surgical stabilization with irradiation is used for impending or complete pathologic fractures.
  • External-beam irradiation is used for painful lesions that do not meet the criteria for pathologic fracture.
  • Medical treatment:
    • Orthopaedic surgery consultation to consider surgical stabilization
    • Selected patients are treated with bone marrow transplantation.
      • Diphosphonate therapy has become an
        integral component of medical therapy because these drugs effectively
        halt osteoclastic bone resorption.
  • Bone marrow transplantation commonly is offered.
Limited activity, according to the level of symptoms and the nature of the bony lesions
  • NSAIDs or narcotic analgesics for pain control
  • Chemotherapeutics (prednisone, alkylating agents)
  • Mostly internal fixation for stabilization of the long bones
  • Decompression with spinal instrumentation may be necessary for patients with pathologic fractures and neurologic deficits.
  • Prognosis is related to the stage of the disease, with an overall median survival of 18–24 months (1).
    • Virtually all patients eventually die of the disease.
  • Bone marrow transplantation currently is being tried in an attempt to cure selected patients.
  • Pathologic fractures
  • Spinal stenosis with compressive myelopathy
  • Renal failure
  • Amyloidosis (CTS)
Patient Monitoring
  • Monitor closely for impending pathologic
    fractures so that appropriate surgical intervention can occur before
    completion of pathologic fractures.
  • Patients undergoing chemotherapy are monitored for changes in their serum protein levels to assess the response to treatment.
1. McCarthy
EF, Frassica FJ. Plasma cell dyscrasia. In: Pathology of Bone and Joint
Disorders: With Clinical and Radiographic Correlation. Philadelphia: WB
Saunders, 1998:185–193.
2. Kyle RA. Multiple myeloma: review of 869 cases. Mayo Clin Proc 1975;50:29–40.
  • 238.6 Solitary myeloma
  • 302.0 Multiple myeloma
Q: What is multiple myeloma?
A: Multiple myeloma is a malignant proliferation of plasma cells with end organ damage to bone and the kidneys.

Q: Do all patients with multiple myeloma need diphosphonate therapy?
Yes, the diphosphonates are very effective in halting the osteoclastic
bone resorption. The number of fractures of the long bones and vertebra
are decreased markedly.
Q: When is surgery necessary in patients with multiple myeloma?
Patients with impending fractures or those with severe weightbearing
pain benefit from prophylactic fixation. Patients with a complete
fracture are treated with internal fixation or a prosthetic

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