1. Comminuted fractures in general
   • Initial assessment and resuscitation
   • Imaging and fracture classification
   • Principles of reduction, stabilization, fixation, bone grafting, and rehabilitation
   • Complications: infection, nonunion, malunion, compartment syndrome, and post-traumatic stiffness
2. Open comminuted tibial fracture, Gustilo-Anderson type IIIB
   • Orthopaedic emergency requiring ATLS-based resuscitation, urgent IV antibiotics, tetanus prophylaxis, sterile dressing and splintage
   • Formal operative irrigation and radical debridement, repeated as needed
   • Temporary external fixation followed by definitive fixation when appropriate
   • Early coordinated soft-tissue coverage, usually flap reconstruction, with plastic surgery involvement
   • Surveillance for infection, compartment syndrome, vascular injury, delayed union/nonunion
3. Multiple myeloma: diagnostic modalities and findings
   • Clinical assessment plus blood tests: CBC, ESR, renal function, calcium, total protein, serum electrophoresis/immunofixation, serum free light chains
   • Urine testing for Bence Jones protein
   • Bone-marrow aspiration/biopsy and cytogenetics
   • Imaging: low-dose whole-body CT, PET-CT or MRI; skeletal radiographs may show punched-out lytic lesions
   • Diagnosis is based on clonal plasma cells plus myeloma-defining events, including CRAB features or biomarker criteria
4. Pott's spine
   • Symptoms, neurological assessment, deformity and abscesses
   • X-ray, MRI, CT-guided biopsy, microbiology and molecular testing
   • Multidrug antituberculous therapy, bracing/selective immobilisation, and indications for decompression/stabilisation
5. Ankylosing spondylitis
   • Inflammatory back pain, sacroiliitis, spinal stiffness and reduced chest expansion
   • Extra-articular disease such as acute anterior uveitis, psoriasis, inflammatory bowel disease, and cardiac involvement
   • Diagnosis by clinical assessment, sacroiliac imaging, inflammatory markers and HLA-B27 support
   • Treatment: exercise and physiotherapy, NSAIDs, biologic therapy when active disease persists, and management of complications

• Definition and pathogenesis
• Early versus late-onset paraplegia
• Clinical features and neurological examination
• Investigations, especially MRI
• Antituberculous therapy
• Indications for surgical decompression, drainage, correction/stabilisation
• Rehabilitation and prognosis

1. Comminuted fractures in general
   • Initial assessment and resuscitation
   • Imaging and fracture classification
   • Principles of reduction, stabilization, fixation, bone grafting, and rehabilitation
   • Complications: infection, nonunion, malunion, compartment syndrome, and post-traumatic stiffness
2. Open comminuted tibial fracture, Gustilo-Anderson type IIIB
   • Orthopaedic emergency requiring ATLS-based resuscitation, urgent IV antibiotics, tetanus prophylaxis, sterile dressing and splintage
   • Formal operative irrigation and radical debridement, repeated as needed
   • Temporary external fixation followed by definitive fixation when appropriate
   • Early coordinated soft-tissue coverage, usually flap reconstruction, with plastic surgery involvement
   • Surveillance for infection, compartment syndrome, vascular injury, delayed union/nonunion
3. Multiple myeloma: diagnostic modalities and findings
   • Clinical assessment plus blood tests: CBC, ESR, renal function, calcium, total protein, serum electrophoresis/immunofixation, serum free light chains
   • Urine testing for Bence Jones protein
   • Bone-marrow aspiration/biopsy and cytogenetics
   • Imaging: low-dose whole-body CT, PET-CT or MRI; skeletal radiographs may show punched-out lytic lesions
   • Diagnosis is based on clonal plasma cells plus myeloma-defining events, including CRAB features or biomarker criteria
4. Pott's spine
   • Symptoms, neurological assessment, deformity and abscesses
   • X-ray, MRI, CT-guided biopsy, microbiology and molecular testing
   • Multidrug antituberculous therapy, bracing/selective immobilisation, and indications for decompression/stabilisation
5. Ankylosing spondylitis
   • Inflammatory back pain, sacroiliitis, spinal stiffness and reduced chest expansion
   • Extra-articular disease such as acute anterior uveitis, psoriasis, inflammatory bowel disease, and cardiac involvement
   • Diagnosis by clinical assessment, sacroiliac imaging, inflammatory markers and HLA-B27 support
   • Treatment: exercise and physiotherapy, NSAIDs, biologic therapy when active disease persists, and management of complications

• Definition and pathogenesis
• Early versus late-onset paraplegia
• Clinical features and neurological examination
• Investigations, especially MRI
• Antituberculous therapy
• Indications for surgical decompression, drainage, correction/stabilisation
• Rehabilitation and prognosisThis set contains five long-answer topics. To keep each answer clinically accurate and exam-usable, choose the one to cover fully first.The complete set is best handled as five separate long-answer notes:

1. General management of comminuted fractures
   • Resuscitation, limb assessment, imaging
   • Principles of biological fixation, choice of implant, bone loss and grafting
   • Prevention and management of infection, nonunion, malunion and stiffness
2. Open comminuted tibial fracture, Gustilo-Anderson type IIIB
   • Emergency management and antibiotics
   • Debridement, temporary fixation, definitive skeletal stabilisation
   • Soft-tissue cover, flap planning, bone reconstruction and rehabilitation
3. Multiple myeloma: diagnostic modalities and findings
   • Blood and urine studies
   • Bone-marrow examination, immunophenotyping and cytogenetics
   • Whole-body imaging and diagnostic criteria
4. Pott’s paraplegia
   • Definition, mechanisms, early versus late paraplegia
   • Examination, imaging and microbiological confirmation
   • Antituberculous therapy, indications for surgery, rehabilitation and prognosis
5. Ankylosing spondylitis
   • Etiology, clinical and extra-articular features
   • Diagnosis, imaging and classification
   • Exercise, NSAIDs, biologics, complications and surgical indications

1. Comminuted fractures: general management
   • Fracture biology, initial trauma assessment, imaging, reduction and fixation principles
   • Relative versus absolute stability, external fixation, nailing, plating, bone grafting and complications
2. Open comminuted fracture of tibia, Gustilo-Anderson IIIB
   • Emergency treatment, antibiotics and tetanus prophylaxis
   • Radical debridement, skeletal fixation, early flap cover, bone defect reconstruction, infection/nonunion care
3. Multiple myeloma: diagnostic modalities and findings
   • Symptoms and CRAB/myeloma-defining events
   • Serum and urine monoclonal-protein studies, marrow examination, cytogenetics and whole-body imaging
4. Pott’s paraplegia
   • Tuberculous spinal cord dysfunction, mechanisms, clinical staging, imaging and tissue diagnosis
   • Antituberculous therapy, decompression/stabilisation indications, rehabilitation and prognosis
5. Ankylosing spondylitis
   • Inflammatory axial disease, sacroiliitis, extra-articular features, imaging and classification
   • Exercise, NSAIDs, biologic/targeted therapy, fracture precautions and deformity surgery

1. General management of comminuted fractures
   • Definition and fracture biology
   • Initial assessment: ATLS, neurovascular status, compartment syndrome
   • Radiographs/CT and pre-operative planning
   • Principles of reduction and fixation: preserve soft-tissue attachment and blood supply; accept indirect reduction where appropriate
   • External fixation, intramedullary nailing, bridge plating, circular fixation
   • Bone loss, grafting, bone transport, rehabilitation
   • Complications: infection, delayed union, nonunion, malunion, stiffness, implant failure
2. Open comminuted tibial fracture, Gustilo-Anderson IIIB
   • Definition: extensive soft-tissue injury with exposed bone/periosteal stripping and inadequate local coverage, usually requiring flap cover
   • Emergency treatment: resuscitation, sterile saline dressing, splintage, photographs/documentation, IV antibiotics promptly, tetanus prophylaxis, analgesia
   • Operative management: thorough irrigation, radical debridement, removal of nonviable tissue/contamination, repeat debridement as required
   • Stabilisation: usually spanning external fixation initially, followed by tailored definitive fixation
   • Orthoplastic approach: early definitive soft-tissue coverage by local/free flap, ideally coordinated with fixation
   • Management of bone defects, infection surveillance, nonunion and rehabilitation
   • Limb salvage versus amputation decision-making
3. Multiple myeloma: diagnostic modalities and findings
   • Definition and plasma-cell dyscrasia spectrum
   • Symptoms and signs, including bone pain, pathological fractures, anaemia, recurrent infection, renal dysfunction, hypercalcaemia and neurological complications
   • Blood studies: CBC, ESR, renal profile, calcium, albumin, LDH, beta-2 microglobulin, serum protein electrophoresis, immunofixation, serum free-light-chain assay
   • Urine studies: 24-hour urine electrophoresis/immunofixation and light-chain proteinuria
   • Bone-marrow aspiration/biopsy: clonal plasma cells, morphology, flow cytometry, FISH/cytogenetics
   • Imaging: whole-body low-dose CT, PET-CT, MRI and selected plain radiographs
   • Diagnostic criteria: clonal marrow plasma cells or plasmacytoma plus CRAB features or specified myeloma-defining biomarkers
   • Staging, prognostic markers and brief treatment outline
4. Pott’s paraplegia
   • Definition: paraparesis/paraplegia due to tuberculous disease of the spine
   • Pathogenesis: cord compression by epidural abscess, granulation tissue, caseous material, sequestrum, vertebral collapse/kyphosis or late fibrosis
   • Early versus late-onset neurological deficit
   • Clinical assessment: constitutional symptoms, spinal pain/deformity, cold abscess, complete neurological examination, bowel/bladder status
   • Investigations: ESR/CRP, microbiological confirmation where feasible, radiographs, MRI as key test, CT for bony anatomy and image-guided biopsy
   • Treatment: multidrug antituberculous therapy, nutritional support, immobilisation/selective bracing, pressure-area care, bladder/bowel care and rehabilitation
   • Surgical indications: worsening or severe neurological deficit, significant compression, instability, progressive deformity, large abscess, uncertain diagnosis, failed medical treatment
   • Procedures: decompression and debridement, abscess drainage, anterior/posterior stabilisation as indicated
   • Prognosis and prevention of disability
5. Ankylosing spondylitis / radiographic axial spondyloarthritis
   • Definition, epidemiology and genetic association including HLA-B27
   • Pathogenesis: enthesitis, sacroiliitis, osteoproliferation and ankylosis
   • Clinical features: inflammatory back pain, sacroiliac pain, morning stiffness, reduced spinal mobility, peripheral arthritis, enthesitis and hip involvement
   • Extra-musculoskeletal manifestations: acute anterior uveitis, psoriasis, inflammatory bowel disease, aortic disease and restrictive chest-wall mechanics
   • Examination: posture, occiput-to-wall distance, chest expansion, modified Schober test, sacroiliac provocation, hip and enthesis examination
   • Investigations: ESR/CRP, HLA-B27 as supportive rather than diagnostic, pelvic radiographs, MRI sacroiliac joints/spine, classification concepts
   • Management: education, smoking cessation, daily posture/spinal-extension exercise, physiotherapy, NSAIDs, local steroid injections where appropriate
   • Escalation for persistent active disease: TNF inhibitors, IL-17 inhibitors, and selected targeted therapies under rheumatology supervision
   • Complications: spinal fracture after minor trauma, osteoporosis, kyphosis, hip destruction, neurological injury and cardiovascular/ocular disease
   • Surgical care: hip replacement when needed and corrective osteotomy in selected fixed deformity.

1. Comminuted Fracture of Tibia

Definition

Relevant Anatomy

• Tibia is the major weight-bearing bone of the leg.
• It has a poor soft-tissue envelope, especially over the anteromedial surface.
• Blood supply:
  • Nutrient artery supplies the inner two-thirds of cortex.
  • Periosteal vessels supply the outer cortex.
  • Extensive stripping of periosteum or repeated open reduction compromises healing.
• A tibial fracture can injure:
  • Anterior tibial artery
  • Posterior tibial artery
  • Peroneal artery
  • Deep peroneal nerve
  • Common peroneal nerve in proximal injuries
• The leg has four compartments: anterior, lateral, superficial posterior, deep posterior. Compartment syndrome must always be excluded.

Mechanism of Injury

High-energy injury

• Road-traffic accident
• Pedestrian struck by vehicle
• Fall from height
• Industrial/crush injury
• Gunshot injury

Low-energy injury

• Twisting injury, especially in osteoporotic bone
• May produce a spiral fracture but is less likely to be severely comminuted.

Classification

1. AO/OTA classification

• 42-A: simple fracture
• 42-B: wedge fracture
• 42-C: complex fracture
  Includes segmental and highly comminuted fractures.

2. Open fracture classification: Gustilo-Anderson

Clinical Features

Symptoms

• Severe pain in leg
• Inability to bear weight
• Swelling and deformity
• Bleeding or wound in open fractures
• Paraesthesia or numbness
• Pain out of proportion, particularly with passive stretch, suggests compartment syndrome.

Signs

• Deformity, shortening, rotation
• Swelling, bruising, fracture blisters
• Crepitus and abnormal mobility, though repeated elicitation must be avoided
• Open wound, exposed bone, contamination
• Skin tenting or threatened skin
• Distal pulses, capillary refill and limb temperature
• Motor and sensory examination:
  • Deep peroneal nerve: first dorsal web-space sensation, great-toe extension
  • Superficial peroneal nerve: dorsum of foot sensation
  • Tibial nerve: sole sensation, toe flexion

Important warning signs

Compartment syndrome: the 6 Ps

• Pain out of proportion
• Pain on passive stretch
• Paraesthesia
• Pallor
• Paralysis
• Pulselessness, a late sign

Investigations

1. Radiographs

• Anteroposterior and lateral radiographs of the entire tibia and fibula
• Include knee and ankle joints
• Assess:
  • Level and pattern of fracture
  • Degree of comminution
  • Length and alignment
  • Translation, angulation and rotation
  • Segmental component
  • Associated fibular fracture
  • Intra-articular extension

2. CT scan

• Fracture extends into knee or ankle joint
• Complex proximal or distal metaphyseal fracture
• Preoperative planning is needed
• Occult fracture pattern needs clarification

3. CT angiography

• Absent or diminished pulses
• Expanding haematoma
• Active bleeding
• Ischaemic limb
• ABI <0.9, where used locally

4. Compartment-pressure measurement

5. Baseline laboratory tests

• CBC
• Blood group and cross-match in major trauma
• Renal function and electrolytes
• Coagulation profile
• Blood glucose
• Infection-related tests in open fractures as required

Initial Management

A. Resuscitation

• Airway with cervical-spine protection
• Breathing
• Circulation: control haemorrhage, gain IV access, resuscitate appropriately
• Disability: neurological status
• Exposure: examine entire limb and patient, prevent hypothermia

B. Limb care

• Give adequate analgesia.
• Cover an open wound with a sterile saline-moistened dressing.
• Document wound size, contamination, neurovascular status, and photographs where permitted.
• Realign gross deformity gently if vascular compromise or threatened skin is present.
• Apply a well-padded long-leg splint.
• Elevate only if this does not compromise arterial perfusion.
• Repeat and document neurovascular examination after reduction and splintage.

C. Open-fracture measures

• Start IV antibiotics as soon as possible, ideally within 1 hour for open fractures, according to local protocol.
• Give tetanus prophylaxis as indicated.
• Do not repeatedly inspect or probe the wound.
• Avoid emergency-department wound washout of a major open long-bone fracture if it delays proper operative debridement.

Principles of Definitive Treatment

Goals

1. Restore length.
2. Correct axial alignment.
3. Correct rotational deformity.
4. Restore joint congruity if intra-articular.
5. Achieve adequate stability for healing.
6. Preserve fracture biology and soft-tissue blood supply.
7. Permit early movement of knee and ankle.
8. Prevent infection, nonunion, malunion and stiffness.

Biological fixation

• Reduce the main proximal and distal segments.
• Restore length, alignment and rotation.
• Preserve soft-tissue attachments to intermediate fragments.
• Use indirect reduction and bridge fixation where possible.
• Accept that small comminuted fragments may unite by callus formation without direct fixation.

Methods of Treatment

A. Nonoperative treatment

Indications

• Stable, minimally displaced fractures
• Patients unsuitable for anaesthesia or surgery
• Selected low-demand patients
• Temporary treatment pending definitive surgery

Method

• Above-knee plaster initially
• Conversion to patellar tendon-bearing cast or functional brace later
• Serial radiographs to monitor alignment

Limitations in comminuted fractures

B. Intramedullary nailing

Indications

• Most closed displaced and comminuted tibial-shaft fractures
• Many type I, II and selected IIIA open fractures after appropriate debridement
• Segmental fractures where the medullary canal allows nailing

Advantages

• Load-sharing fixation
• Preserves fracture haematoma and periosteal supply
• Smaller exposure than plating
• Restores length and alignment
• Enables early knee and ankle movement
• Allows earlier weight bearing when fixation and soft tissues permit

Technique principles

• Closed or minimally invasive reduction
• Reamed or unreamed nail depending on fracture, soft-tissue state and surgeon preference
• Proximal and distal locking screws
• Blocking screws may assist alignment in proximal or distal metaphyseal fractures
• Confirm length, rotation and alignment fluoroscopically

Complications

• Anterior knee pain
• Malalignment, especially in proximal or distal-third fractures
• Infection
• Delayed union/nonunion
• Broken locking screws or nail
• Fat embolism, uncommon
• Missed compartment syndrome

C. Plate fixation

Indications

• Proximal or distal metaphyseal tibial fractures not controllable with a nail
• Intra-articular extension requiring reduction of the articular surface
• Selected nonunions or malunions
• Polytrauma when a plate strategy is most appropriate

Technique

• Locking plate, usually using minimally invasive plate osteosynthesis
• Bridge plate over comminuted zone
• Fix proximal and distal main fragments while avoiding unnecessary dissection at fracture site

Disadvantages

• Wound complication and infection risk due to subcutaneous tibia
• Periosteal stripping if extensive open exposure is used
• Possible implant failure or nonunion

D. External fixation

Indications

• Severe open fracture with contamination or major soft-tissue injury
• Physiologically unstable polytrauma patient: damage-control orthopaedics
• Vascular injury requiring repair
• Compartment syndrome after fasciotomy
• Segmental bone loss
• Infected nonunion
• Need for bone transport
• When definitive fixation must be delayed

Types

• Monolateral external fixator
• Spanning external fixator
• Circular Ilizarov or hexapod frame

Advantages

• Rapid stabilisation
• Minimal disturbance of fracture zone
• Facilitates wound access, repeated debridement and flap cover
• Circular frames can correct deformity and permit bone transport

Complications

• Pin-tract infection
• Loss of reduction
• Joint stiffness
• Delayed union
• Neurovascular injury from pin placement
• Refracture after removal

E. Bone loss and reconstruction

Options

• Acute shortening and later lengthening
• Autologous cancellous bone grafting for small defects
• Masquelet induced-membrane technique
• Bone transport using circular external fixation
• Vascularised fibular graft in selected major defects
• Allograft or bone substitutes in selected settings

Management of an Open Gustilo IIIB Comminuted Tibial Fracture

Definition

• High-energy fracture
• Extensive soft-tissue loss
• Periosteal stripping and exposed bone
• Inadequate local soft-tissue cover
• Requirement for local or free flap reconstruction

Emergency treatment

1. ATLS resuscitation.
2. IV antibiotics promptly and tetanus prophylaxis.
3. Sterile saline-moistened dressing.
4. Photograph/document wound and neurovascular state.
5. Realign and splint.
6. Urgent transfer to a centre capable of combined orthopaedic and plastic surgery care.
7. Assess limb viability and associated vascular injury.

Operative debridement

• Remove foreign material, clothing, soil and devitalised tissue.
• Excise nonviable skin, fat, fascia, muscle and loose avascular bone fragments.
• Preserve viable cortical fragments with soft-tissue attachments.
• Extend wounds safely using fasciotomy-type approaches when required.
• Take deep samples if infection is suspected, but do not delay antibiotics.
• Repeat debridement if viability remains doubtful.

Skeletal stabilisation

• Temporary spanning external fixation is common initially.
• Definitive fixation options:
  • Intramedullary nail in selected cases
  • Circular external fixator
  • Plate fixation only when immediate definitive soft-tissue coverage is possible

Soft-tissue reconstruction

• Must be planned with the plastic surgeon from the first debridement.
• Options:
  • Local muscle flap, for example gastrocnemius for proximal-third defects
  • Soleus flap for selected middle-third defects
  • Free flap, commonly for distal-third or extensive defects
• Definitive cover should not be unnecessarily delayed. Internal fixation should not be left under an uncovered wound.

Complications

Early

• Haemorrhagic shock in polytrauma
• Open-fracture contamination and infection
• Compartment syndrome
• Vascular injury and limb ischaemia
• Nerve injury
• Deep vein thrombosis and pulmonary embolism
• Fat embolism syndrome
• Wound necrosis

Late

• Delayed union
• Nonunion, especially at the distal tibial third
• Malunion: varus, valgus, procurvatum, recurvatum, shortening or rotational deformity
• Chronic osteomyelitis
• Implant failure
• Knee and ankle stiffness
• Chronic pain
• Complex regional pain syndrome
• Post-traumatic osteoarthritis if joint involved

Follow-up and Rehabilitation

• Serial wound and neurovascular assessment.
• Radiographs at regular intervals to assess alignment and union.
• Early active knee, ankle and toe movements.
• Weight bearing according to fracture stability, fixation method and soft-tissue condition.
• Thromboprophylaxis when indicated.
• Optimise nutrition, vitamin D status, smoking cessation and diabetic control.
• Treat pin-tract infection early in external fixation.
• Assess for union clinically and radiologically.

2. Multiple Myeloma

Definition

1. Monoclonal gammopathy of undetermined significance (MGUS)
2. Smouldering multiple myeloma
3. Symptomatic multiple myeloma
4. Plasma-cell leukaemia
5. Solitary plasmacytoma

Pathogenesis

• Malignant plasma cells proliferate in bone marrow.
• They secrete monoclonal immunoglobulin, called M protein, or monoclonal light chains.
• They stimulate osteoclast activity and suppress osteoblasts, causing osteolytic lesions.
• They displace normal marrow, producing anaemia, thrombocytopenia and leukopenia.
• They suppress normal immunoglobulin production, causing recurrent infection.
• Light chains cause cast nephropathy and renal impairment.

Clinical Features

A. Bone disease

• Persistent bone pain, especially back, ribs, pelvis and skull
• Pain worsened by movement
• Vertebral compression fracture
• Pathological fracture
• Spinal cord compression
• Osteoporosis and lytic lesions

B. Marrow failure

• Normocytic normochromic anaemia: fatigue, dyspnoea, pallor
• Leukopenia and recurrent infection
• Thrombocytopenia and bleeding tendency

C. Renal disease

• Renal impairment or acute kidney injury
• Proteinuria, often light chains
• Cast nephropathy
• Contributing factors: dehydration, hypercalcaemia, sepsis, NSAIDs and contrast exposure

D. Hypercalcaemia

• Thirst, polyuria, constipation
• Nausea and vomiting
• Confusion, drowsiness or coma
• Cardiac arrhythmia

E. Infection

• Recurrent bacterial infection, especially pneumonia and urinary infection
• Hypogammaglobulinaemia causes susceptibility to encapsulated organisms

F. Hyperviscosity, uncommon

• Headache
• Blurring of vision
• Mucosal bleeding
• Confusion

G. Neurological manifestations

• Spinal cord compression
• Radiculopathy
• Peripheral neuropathy
• Carpal tunnel syndrome in amyloidosis

The CRAB Features

Diagnostic Modalities and Expected Findings

1. Complete blood count and peripheral smear

Findings

• Normocytic normochromic anaemia
• Rouleaux formation due to high serum proteins
• Leukopenia or thrombocytopenia in advanced marrow infiltration
• Raised ESR, often markedly elevated

2. Biochemistry

Essential tests

• Serum calcium, preferably corrected calcium
• Urea, creatinine and eGFR
• Electrolytes
• Albumin and total protein
• Liver function tests
• LDH
• Uric acid
• Beta-2 microglobulin
• Quantitative immunoglobulins

Findings

• Hypercalcaemia
• Renal impairment
• Raised total protein with reduced albumin-to-globulin ratio
• High beta-2 microglobulin, associated with tumour burden and prognosis
• Immunoparesis: reduction of uninvolved immunoglobulins

3. Serum protein electrophoresis

Purpose

Finding

• Narrow monoclonal band or M spike, usually in gamma region
• Usually IgG, then IgA
• A normal electrophoresis does not exclude light-chain myeloma or non-secretory myeloma.

4. Serum immunofixation electrophoresis

Purpose

Example

• IgG-kappa myeloma
• IgA-lambda myeloma

5. Serum free light-chain assay

Purpose

Uses

• Diagnosing light-chain myeloma
• Assessing oligo-secretory disease
• Monitoring response
• Prognostic assessment

6. Urine studies

Tests

• 24-hour urine protein quantification
• Urine protein electrophoresis
• Urine immunofixation

Findings

• Monoclonal free light chains, historically called Bence Jones proteinuria
• Light-chain excretion may be present even without a major serum M spike.

7. Bone marrow aspiration and trephine biopsy

Essential diagnostic test

Findings

• Clonal plasma cells, often ≥10% of nucleated marrow cells
• Plasma cells may show eccentric nucleus, clock-face chromatin and perinuclear hof
• Marrow infiltration may suppress normal haematopoiesis.

Ancillary tests

• Flow cytometry: establishes clonality, typically aberrant CD38/CD138-positive plasma cells with light-chain restriction.
• Cytogenetics/FISH: evaluates risk.

Important high-risk abnormalities

• del(17p)
• t(4;14)
• t(14;16)
• gain or amplification of 1q

8. Imaging

A. Whole-body low-dose CT

B. Whole-body MRI

• Marrow infiltration
• Focal marrow lesions
• Spinal cord compression
• Neurological symptoms
• Occult disease before cortical bone destruction

C. FDG PET-CT

• Active focal bone and extramedullary disease
• Treatment response
• Suspected relapse

D. Conventional skeletal survey

• Punched-out skull lesions
• Generalised osteopenia
• Vertebral compression fractures
• Lytic lesions in long bones, ribs and pelvis

E. Bone scan

Diagnostic Criteria: Symptomatic Multiple Myeloma

A. One of the following

• Clonal marrow plasma cells ≥10%, or
• Biopsy-proven bony or extramedullary plasmacytoma

B. At least one myeloma-defining event

CRAB end-organ injury attributable to myeloma

• Hypercalcaemia: serum calcium >1 mg/dL above the upper normal limit or >11 mg/dL
• Renal impairment: creatinine clearance <40 mL/min or serum creatinine >2 mg/dL
• Anaemia: haemoglobin >2 g/dL below normal or <10 g/dL
• Bone disease: one or more osteolytic lesions on CT, PET-CT or radiography

Biomarkers of malignancy: SLiM criteria

• S: ≥60% clonal bone-marrow plasma cells
• Li: involved/uninvolved serum free-light-chain ratio ≥100, with involved chain ≥100 mg/L
• M: >1 focal lesion on MRI, each at least 5 mm

Differentiation from Related Disorders

Staging and Prognosis

Revised International Staging System

• Serum beta-2 microglobulin
• Serum albumin
• LDH
• High-risk FISH abnormalities

Poor prognostic factors

• High beta-2 microglobulin
• Low albumin
• Elevated LDH
• del(17p), t(4;14), t(14;16), 1q gain/amplification
• Extramedullary disease
• Renal failure
• High tumour burden

Treatment Outline

Supportive treatment

• Hydration and prompt treatment of hypercalcaemia
• Avoid nephrotoxic drugs and unnecessary contrast
• Bisphosphonate or denosumab for myeloma bone disease when appropriate
• Analgesia
• Radiotherapy for painful focal lesions or spinal cord compression
• Orthopaedic stabilisation of impending or completed pathological fracture
• Antimicrobial treatment and selected prophylaxis
• Vaccination
• Red-cell transfusion or erythropoiesis-stimulating agent in selected patients
• Thromboprophylaxis with certain anti-myeloma regimens

Anti-myeloma therapy

• Proteasome inhibitor: bortezomib
• Immunomodulatory drug: lenalidomide
• Corticosteroid: dexamethasone
• Anti-CD38 monoclonal antibody: daratumumab

Transplant-eligible patients

• Induction combination therapy
• Autologous stem-cell transplantation in appropriate patients
• Maintenance therapy, often lenalidomide-based

Emergencies

• Suspected cord compression: urgent MRI, corticosteroid according to specialist protocol, haematology/radiotherapy/spinal-surgery input.
• Hypercalcaemic crisis: IV fluids, antiresorptive therapy and treatment of myeloma.
• Acute kidney injury from light chains: urgent hydration, avoid nephrotoxins and rapidly treat the plasma-cell disorder.

3. Pott’s Paraplegia

Definition

Etiology and Pathogenesis

• From vertebral body to adjacent disc and neighbouring vertebra
• Beneath anterior or posterior longitudinal ligaments
• Into epidural space
• Into paravertebral tissues, producing a cold abscess

Mechanisms producing paraplegia

1. Epidural granulation tissue compressing spinal cord
2. Caseous material in epidural space
3. Epidural or paravertebral abscess
4. Sequestrated bone or disc fragment
5. Vertebral collapse with kyphosis/gibbus
6. Instability or subluxation
7. Tuberculous thrombosis/vasculitis causing cord ischaemia
8. Late fibrosis, adhesions, myelomalacia or bony canal stenosis

Classification

A. According to time of onset

Early-onset paraplegia

Common causes

• Epidural abscess
• Granulation tissue
• Caseous material
• Oedema
• Sequestrum
• Mechanical instability or acute vertebral collapse

Prognosis

Late-onset paraplegia

Causes

• Severe residual kyphosis
• Internal gibbus causing chronic cord stretch or compression
• Fibrosis around dura
• Spinal canal stenosis
• Reactivation of disease

Prognosis

Clinical Features

A. Constitutional symptoms

• Low-grade fever
• Evening rise of temperature
• Night sweats
• Weight loss
• Loss of appetite
• Fatigue

B. Spinal symptoms

• Localised back pain
• Spinal tenderness
• Muscle spasm
• Restricted spinal movement
• Progressive kyphosis or angular gibbus
• Refusal to walk or sit in children

C. Cold abscess

• Paravertebral swelling
• Psoas abscess presenting as groin or thigh swelling
• Retropharyngeal abscess in cervical disease
• Chest-wall swelling in thoracic disease

D. Neurological features

Early upper motor neuron signs

• Stiffness and weakness of lower limbs
• Difficulty walking
• Spastic gait
• Hypertonia
• Exaggerated knee and ankle jerks
• Extensor plantar response
• Ankle clonus

Progression

• Spastic paraparesis
• Sensory impairment with a spinal sensory level
• Bladder urgency, retention or incontinence
• Constipation or faecal incontinence
• Complete paraplegia

Lower motor neuron pattern

• Flaccid weakness
• Reduced reflexes
• Saddle sensory loss
• Urinary retention
• Reduced anal tone

Neurological Examination and Documentation

• Motor power in every key muscle group
• Tone
• Deep-tendon reflexes
• Plantar responses
• Sensory level for light touch, pinprick and vibration
• Perianal sensation and anal tone if indicated
• Sacral sparing
• Gait, if patient can walk
• Bladder and bowel function
• Sexual function where relevant
• Presence of pressure sores

Investigations

1. Blood tests

• CBC: may show anaemia
• ESR and CRP: often elevated but nonspecific
• Renal and liver function baseline before drug therapy
• HIV test with consent, where appropriate
• Blood cultures if pyogenic infection is a possibility

2. Tuberculosis testing

• Tuberculin skin test or interferon-gamma release assay may support TB exposure but cannot prove active spinal disease.
• Sputum examination if pulmonary symptoms or lung lesions are present.

3. Plain radiographs

Early stage

Later findings

• Reduction of intervertebral disc space
• Destruction of adjacent vertebral end plates
• Anterior vertebral wedging
• Vertebral-body collapse
• Kyphosis or gibbus
• Paravertebral shadow from abscess
• Fusion or ankylosis in healing stage

4. MRI: investigation of choice

• Vertebral marrow involvement
• Disc and end-plate destruction
• Epidural abscess or granulation tissue
• Cord compression
• Cord oedema or myelomalacia
• Paravertebral and psoas abscesses
• Multilevel and non-contiguous lesions
• Degree of canal compromise and neural compression

5. CT scan

• Defining bony destruction
• Surgical planning
• Identifying sequestra
• CT-guided aspiration or biopsy

6. Tissue diagnosis

Methods

• CT-guided needle biopsy
• Aspiration of cold abscess
• Open biopsy during decompression

Send for

• Histopathology: granulomas with caseation may be seen
• Acid-fast bacilli smear
• Mycobacterial culture
• Nucleic-acid amplification test, for example Xpert MTB/RIF or equivalent
• Drug-susceptibility testing

Differential Diagnosis

• Pyogenic spondylodiscitis
• Brucellar spondylitis
• Metastatic spinal tumour
• Multiple myeloma
• Lymphoma
• Vertebral osteoporotic collapse
• Fungal vertebral infection
• Ankylosing spondylitis with fracture
• Epidural tumour or abscess from another cause

Management

Principles

1. Diagnose promptly and determine neurological severity.
2. Confirm TB microbiologically when feasible.
3. Start effective antituberculous treatment.
4. Prevent or reverse cord damage.
5. Decompress neural structures when indicated.
6. Stabilise an unstable spine and prevent progressive deformity.
7. Provide bladder, bowel, skin and rehabilitation care.

A. Antituberculous chemotherapy

Usual drug-susceptible regimen

• Intensive phase: isoniazid, rifampicin, pyrazinamide and ethambutol
• Continuation phase: isoniazid and rifampicin

Monitoring

• Adherence and adverse effects
• Clinical improvement: pain, fever, appetite, neurology
• Liver function where indicated
• Visual assessment with ethambutol
• Serial ESR/CRP as supportive markers
• Imaging only when clinically needed, since radiological resolution lags behind clinical recovery

Drug-resistant TB

B. Nonoperative supportive management

• Confirmed or highly probable TB
• Mild and non-progressive neurological deficit
• No major instability
• No severe kyphosis
• No large compressive abscess
• Demonstrable response to treatment

• Analgesia
• Nutrition and protein optimisation
• Vitamin D and bone-health assessment where appropriate
• Short-term brace or orthosis for pain control/instability when indicated
• Prevention of pressure sores
• DVT prevention in immobile patients
• Physiotherapy and safe mobilisation
• Bladder and bowel care

C. Indications for Surgery

1. Progressive neurological deficit despite appropriate chemotherapy
2. Severe neurological deficit with significant cord compression
3. Large epidural abscess or significant mass effect
4. Mechanical instability
5. Severe or progressive kyphosis, especially in children or junctional disease
6. Vertebral collapse causing internal gibbus
7. Diagnostic uncertainty, particularly concern for malignancy or pyogenic infection
8. Failure of conservative treatment, persistent severe pain or worsening deformity
9. Drug-resistant disease requiring debridement or diagnostic tissue
10. Late-onset paraplegia from healed kyphotic deformity or canal stenosis

D. Surgical Principles and Procedures

Surgical aims

• Obtain tissue diagnosis
• Drain abscess
• Remove caseous/necrotic tissue and sequestrum
• Decompress spinal cord
• Correct deformity where safe
• Stabilise the spine
• Facilitate mobilisation

Procedures

• Anterior debridement and decompression with reconstruction
• Posterior decompression and instrumented stabilisation
• Combined anterior-posterior surgery in selected severe cases
• Drainage of paravertebral or psoas abscess, percutaneously or openly
• Deformity correction/osteotomy in selected late kyphotic paraplegia

Bladder and Bowel Care

Bladder

• Assess retention using bladder scan.
• Intermittent clean catheterisation is preferred where feasible.
• Indwelling catheter may be needed initially, but avoid unnecessary prolonged use.
• Monitor for urinary infection.
• Refer for urological/neuro-urological assessment if dysfunction persists.

Bowel

• Regular bowel programme
• Adequate fluids and fibre if appropriate
• Stool softeners or stimulant agents as needed
• Prevent constipation and faecal impaction

Rehabilitation

Prevent complications

• Two-hourly repositioning when immobile
• Pressure-area care
• Passive range-of-motion exercises
• Prevention of contractures
• DVT prevention
• Chest physiotherapy where needed

Restore function

• Strengthening of preserved muscle groups
• Progressive sitting, transfers and standing
• Gait training where feasible
• Orthoses, walker, crutches or wheelchair as required
• Occupational therapy for activities of daily living
• Psychological support
• Social, vocational and sexual-health rehabilitation

Prognosis

• Early diagnosis and treatment
• Early-onset neurological deficit
• Short duration of paralysis
• Incomplete deficit at presentation
• Predominantly soft compressive material, such as abscess/granulation tissue
• Prompt decompression when indicated
• Good adherence and drug-susceptible disease

• Complete longstanding paraplegia
• Late-onset paraplegia
• Cord atrophy, myelomalacia or severe chronic fibrosis on MRI
• Severe rigid kyphosis
• Delayed diagnosis
• Drug-resistant TB
• Poor nutritional status or severe comorbidity

Short Exam Conclusion