Quehaceres de Medicos

El síndrome del túnel carpiano es una fuente común de adormecimiento y dolor de las manos. Aunque a menudo se asocia con movimientos repetitivos de las manos, como teclear, el síndrome del túnel carpiano puede ser causado por muchas cosas.
El síndrome del túnel carpiano es más común en las mujeres que en los hombres.
El nervio mediano viaja desde el antebrazo hacia el interior de la mano a través de este túnel en la muñeca. El nervio mediano controla las sensaciones en el lado palmar de los dedos pulgar, índice y medio. El nervio también controla los músculos alrededor de la base del pulgar. Los tendones que flexionan los dedos de la mano también viajan a través del túnel carpiano. Estos tendones se llaman tendones flexores.
El túnel carpiano es una estructura estrecha, similar a un túnel, en la muñeca. La base y las paredes de este túnel están formadas por los huesos de la muñeca (carpianos). El techo del túnel está cubierto por una fuerte banda de tejido conectivo llamada ligamento carpiano transverso.
El síndrome del túnel carpiano ocurre cuando los tejidos que rodean a los tendones flexores en la muñeca se inflaman y hacen presión en el nervio mediano. Estos tejidos se llaman membrana sinovial. La membrana sinovial lubrica los tendones y facilita el movimiento de los dedos.
La inflamación de la membrana sinovial reduce el espacio limitado del túnel carpiano y, con el paso del tiempo, comprime al nervio.
Muchas cosas contribuyen al desarrollo del síndrome del túnel carpiano:

• La herencia es el factor más importante, los túneles carpianos son más pequeños en algunas personas y este rasgo puede repetirse en las familias.
• El uso de la mano con el paso del tiempo puede jugar un papel.
• Cambios hormonales relacionados al embarazo pueden jugar un papel.
• La edad: la enfermedad ocurre más frecuentemente en personas mayores.
• Condiciones médicas, incluyendo diabetes, artritis reumatoide y desequilibrio de la glándula tiroides pueden jugar un papel.

En la mayoría de los casos de síndrome del túnel carpiano, no hay una única causa.
Los síntomas más comunes del síndrome del túnel carpiano incluyen:

• Adormecimiento, hormigueos y dolor en la mano
• Una sensación de descarga eléctrica, sobre todo en los dedos pulgar, índice y medio
• Sensaciones extrañas y dolor que recorren el brazo y suben hacia el hombro

Los síntomas por lo general comienzan gradualmente, sin una lesión específica. En la mayoría de las personas, los síntomas son más severos en el lado del pulgar de la mano.
Los síntomas pueden ocurrir en cualquier momento. Muchas personas duermen con las muñecas flexionadas, por lo que los síntomas son comunes en la noche y pueden despertarlo de su sueño. Durante el día, los síntomas ocurren con frecuencia cuando se sostiene algo, como un teléfono, o cuando la persona está leyendo o conduciendo un vehículo. Mover o sacudir la mano a menudo ayuda a reducir los síntomas.
Los síntomas inicialmente van y vienen, pero con el paso del tiempo pueden hacerse constantes. Una sensación de torpeza o debilidad puede dificultar la motricidad fina, como abotonarse la camisa. Estas sensaciones pueden provocar que a usted se le caigan las cosas. Si la condición es muy severa, los músculos en la base del pulgar pueden atrofiarse perceptiblemente.
Para determinar si usted tiene síndrome del túnel carpiano, su médico discutirá sus síntomas y sus antecedentes médicos. El médico también examinará su mano y realizará un número de pruebas físicas, como:

• Verificar si hay debilidad en los músculos que rodean la base del pulgar
• Flexionar y sostener sus muñecas en posiciones para comprobar si hay adormecimiento u hormigueos en sus manos
• Presionar sobre el nervio mediano en la muñeca, para ver si ello causa adormecimiento u hormigueo
• Dar golpecitos a lo largo del nervio mediano en la muñeca para ver si ello causa hormigueos en cualquiera de los dedos
• Comprobar la sensibilidad en sus dedos, tocándolos suavemente cuando sus ojos están cerrados

Pruebas electrofisiológicas. Las pruebas eléctricas de la función del nervio mediano a menudo se hacen para ayudar a confirmar el diagnóstico y dilucidar la mejor opción de tratamiento en su caso.
Radiografías. Si usted tiene movimientos limitados de la muñeca, su médico podría indicar estudios de rayos-X de su muñeca.
Para la mayoría de las personas, el síndrome del túnel carpiano empeorará progresivamente si no se realiza algún tipo de tratamiento. La condición podría, sin embargo, modificarse o detenerse en las etapas tempranas. Por ejemplo, si los síntomas se relacionan definitivamente con una actividad u ocupación, la condición puede que no avance si la ocupación o actividad se interrumpe o se modifica.

Si alguna vez el médico le dijo que tenía elevado el nivel de azúcar en la sangre, aunque sólo hubiese sido una vez cuando estaba embarazada, corre riesgo de ser diabética. Son aproximadamente 23 millones de personas (15 por ciento de la población de los Estados Unidos) las que sufren la enfermedad. Una de las mayores complicaciones es el deterioro del sistema nervioso (neuropatía), pérdida de sensibilidad en los piés y manos, debido a lo cual, en caso de lastimarse no se dará cuenta inmediatamente. Este problema afecta entre el 60 por ciento y el 70 por ciento de los diábeticos.
Los problemas en los piés son un gran riesgo, por lo tanto como todos los diabéticos, deberá controlarlos, si no lo hiciera las consecuencias podrían ser graves, inclusive puede llegar a la amputación o aún peor.
Las lastimaduras menores pueden terminar siendo problemas que requieran cuidados de emergencia. En caso de diabéticos, una herida tan pequeña como una ampolla producida por el roce el zapato puede terminar causando mucho daño. La diabetes disminuye el flujo sanguíneo y por lo tanto las heridas cicatrizan lentamente y si la herida no cicatriza, existe riesgo de infección y en los diabéticos las infecciones avanzan rápidamente.
Si sufre de diabetes, deberá revisarse los pies diariamente, fíjese si tiene pinchaduras, moretones, zonas que duelan al tacto, piel roja, temperatura en la piel, ampollas, úlceras, raspaduras, cortes y problemas en las uñas. Pídale a alguien que lo ayude o utilice un espejo, fíjese si el pie está hinchado, examínese entre los dedos. Deberá controlar seis lugares en la planta del pie, la punta del dedo gordo; la base de los dedos meñiques; la base de los dedos medios; el talón; la parte lateral del pie y la base del pie. Controle si tiene sensibilidad en los dos pies.
En caso de encontrar una lastimadura, no importa cuan insignificante sea, no trate de curársela usted mismo, vea inmediatamene al médico.
Algunas de las recomendaciones básicas son:

• Lávese los pies diaramente con jabón suave y agua tibia, primero pruebe la temperatura del agua con la mano, no ponga los pies en remojo. Séquelos suavemente presionando con una tohalla, tenga mucho cuidado al secar entre los dedos.
• Use crema de buena calidad y mantenga la piel de los pies bien humectada, no se ponga crema entre los dedos.
• Corte las uñas de los pies en forma recta y evite cortar los lados. Utilice sólo lima de uñas o papel esmeril. Si tiene una uña encarnada vea a un médico.
• No utilice lociones antisépticas, medicamentos de farmacia sin receta, almohadillas de calor o instrumentos cortantes. No acerque los pies a radiadores o chimeneas.
• Manténgalos siempre calientes, utilice medias que le queden flojas. Evite mojar los piés cuando llueve o nieva y utilice medias abrigadas en invierno.
• No fume y no se cruce de piernas, éstas actividades disminuyen el flujo sanguíneo a los pies.

Algunas recomendaciones caseras sobre zapatos y medias:

• Nunca ande descalzo, en zandalias o zapatos con tirillas de cuero entre los dedos.
• Tenga mucho cuidado con los zapatos que elije y los que usa, compre su zapatos en la tarde cuando los pies están más hinchados y fíjese que sea cómodo y que no sea necesario "amoldarlos," que le queden bien de ancho, largo, de atrás, la base del talón y la suela. Evite comprar zapatos con punta o muy altos. Trate de comprar zapatos de cueron en la parte superior y con mucho espacio para los dedos. Cuando los zapatos son nuevos, úselos sólo unas dos horas o menos por día. No use los mismo zapatos todos los días, revíselos antes de usarlos y no use los cordones ni muy apretados ni muy flojos.
• Tenga mucho cuidado al elegir las medias. Utilice medias limpias y secas todos los días y evite utilizar las que tengan agujeros o arrugas. Las medias delgadas de algodón son más absorbentes para el verano. Las medias de punta cuadrada no aprietan los dedos, evite las medias con elástico en la parte superior.

Al perder la sensiblidad en los pies existe el riesgo de deformación, ésto puede deberse a úlceras, ya que las heridas abiertas pueden infectarse. Otra manera es una condición ósea conocida con el nombre de pie Charcot. Este es uno de los problemas más graves, ya que el pie se tuerce cuando los huesos se fracturan y se desintegran, Ud. sigue caminando igual porque no siente dolor.
El médico puede tratar las úlceras del pie diabético y las etapas iniciales de las fracturas de pie Charcot con una yeso de contacto. La forma de su pie le da la forma al yeso, permite que la úlcera se cure ya que distribuye el peso y alivia la presión. En caso de tener pie de Charcot, el yeso controla el movimiento del mismo, los bordes le brindan apoyo al pie, no debe poner peso sobre le pie. Es necesario tener un buen flujo sanguíneo para poder usar un yeso de contacto. El médico lo controlará de cerca y cambiará el yeso cada una o dos semanas hasta que el pie esté totalmente curado.
Otra forma de tratar el pie de Charcot es mediante una bota de yeso, le brinda apoyo al pie hasta que desaparezca la hinchazón lo que puede tardar hasta un año. Evite colocar peso sobre el pie de Charcot. Se podrá considerar cirugía si la deformación fuese demasiado grave como para poder corregirla con el yeso o con un zapato.

In 1999, the Institute of Medicine (IOM) issued a report, To Err Is Human: Building a Safer Health System. According to this report, 44,000 to 98,000 people die in hospitals each year as the result of medical errors that could be prevented. These figures would make medical errors the eighth leading cause of death in the U.S., ahead of deaths from motor vehicle accidents, breast cancer or AIDS. Medication errors alone may be responsible for about 7,000 deaths per year.
The IOM defines patient safety as freedom from accidental injury and medical error. Medical error is "the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim."
Errors occur in hospitals as well as in other health care settings, such as physicians' offices, nursing homes, pharmacies, urgent care centers, and homes. Unfortunately, very little data exist on the extent of the problem outside of hospitals. The IOM report indicated, however, that many errors probably occur outside the hospital.
Medical errors are costly. The IOM report estimates that medical errors cost the nation about $37.6 billion each year. About $17 billion of those costs are associated with preventable errors. About half of the expenditures for preventable medical errors are for direct health care cost.
Awareness of the problems of medical errors and patient safety has been growing. Americans have a very real fear of medical errors. According to a national poll conducted by the National Patient Safety Foundation:

• Four out of 10 people who responded (42 percent) had been affected by a medical error, either personally or through a friend or relative.
• Nearly one third of people who responded (32 percent) indicated that the error had a permanent negative effect on the patient's health.

Overall, the people who responded thought the health care system was "moderately safe." But another survey, conducted by the American Society of Health-System Pharmacists, found that Americans are "very concerned" about:

• Being given the wrong medicine (61 percent).
• Being given two or more medicines that interact in a negative way (58 percent).
• Complications from a medical procedure (56 percent).

Where's the problem? Most people believe that medical errors are the fault of a healthcare provider. When asked about possible solutions to medical errors:

• Three out of four people who responded thought it would be most effective to "keep health professionals with bad track records from providing care."
• Nearly 70 percent thought the problem could be solved through "better training of health professionals."

But the IOM report said that most medical errors are not due to a person. Instead, they are related to the way things happen. The key to reducing medical errors is to improve the way care is delivered and not to blame a person. Health care professionals are human. Like everyone else, they make mistakes. Improving the system can reduce error rates and improve the quality of health care:

• A 1999 study showed that if a pharmacist went along with doctors on medical rounds, errors related to medication ordering could drop by as much as 66 percent.
• Using standard guidelines, establishing protocols, and standardizing equipment has reduced errors related to anesthesia by nearly sevenfold.
• One veteran's hospital uses hand-held computers and bar codes for ordering medicines. The hospital's medication error rate dropped by 70 percent. Soon, all VA hospitals will use this system.

Most people believe that medical errors usually involve drugs or surgeries where something goes wrong. A patient may get the wrong prescription or dosage, or a sponge used to soak up blood during a surgery may be left in the patient. However, there are many other types of medical errors, including:

• Diagnostic errors. The wrong diagnosis may mean that the patient doesn't get the right kind of therapy or treatment. Test results could be misinterpreted. The patient may fail to receive an indicated diagnostic test.
• Equipment failure. Perhaps a battery is dead, or a valve pump doesn't work properly.
• Infections. The patient may get an infection unrelated to the illness while in the hospital, or a surgical site may become infected.
• Blood transfusion-related injuries. A patient may receive blood that doesn't match his or her own blood type.
• Misinterpreted medical orders. A doctor prescribes a "no salt" diet, but the hospitalized patient gets a meal seasoned with salt.

Research indicates that more than half, and maybe as many as 75 percent, of medical errors can be prevented. For example:

• Using computers to order medications and treatments could eliminate problems with not understanding a doctor's handwriting.
• Medicine packages and names should look and sound different to prevent mix-ups and confusion.
• Standard treatment policies and protocols help avoid confusion about what to do and what works best in most cases.

The American Academy of Orthopaedic Surgeons (AAOS) believes that patient safety is a major concern. It is working to reduce medical errors through its Patient Safety Committee. The AAOS and other organizations of healthcare professionals, hospitals and consumers are developing a national plan to measure healthcare quality and ensure accurate reporting of errors. It also has a public education campaign called "Take Care: Patient Safety Is No Accident." Talk to your orthopaedic surgeon about preventing medical errors.

Osteoporosis is generally a progressive and painless condition. But one type of osteoporosis is both reversible and painful. Because it isn't permanent and is usually most obvious in the hip joint, this condition is called transient osteoporosis of the hip.

• Women in the late stages of pregnancy (after the sixth month)
• Middle-aged men (between 40 and 70 years old)

• Sudden onset of pain, typically in the front of the thigh, the side of the hip, the buttocks or the groin.
• No previous accident or injury to the joint that would trigger pain.
• Limited motion; pain intensifies with turning movements.
• Pain intensifies with weight bearing and may lessen with rest.
• Pain gradually increases over a period of weeks or month and may be so intense that it is disabling.
• A change in gait as the patient tries to protect the joint and ease the pain.

A diagnosis of transient osteoporosis of the hip is usually made by eliminating other possible causes of hip pain, such as a muscle injury or stress fracture. Your doctor will ask you whether you can remember any injury to the joint. You may also be asked to do certain range-of-motion tests to replicate the pain. Because X-rays may not show bone loss until the condition is well-advanced, your physician may request an MRI (magnetic resonance image) or bone scan to confirm the diagnosis. If you are pregnant, your physician may elect to delay any imaging studies until the last stages of your pregnancy, or even until after the delivery.
As yet, there is no clear explanation for what causes this condition. Although it is most common in the hip joint, multiple joints may be affected.
This condition generally resolves by itself over 6 to 12 months. Treatment focuses on preventing any damage while bones are weakened by osteoporosis. If you are pregnant, this condition increases your risk of a hip fracture.

• Your physician may prescribe a mild pain reliever.
• Using crutches, a cane, or other walking aids will help relieve the stress of weight bearing on the joint.
• To help maintain strength and flexibility in the muscles, your physician may also recommend a series of flexibility and range-of-motion exercises that you can do as the pain subsides. Aquatic exercises may be helpful not only because they ease movement, but also because they relieve weight bearing.

Osteoporosis is a disease of progressive bone loss associated with an increased risk of fractures. The term osteoporosis literally means "porous bone." Diagnosis of osteoporosis involves a measurement of bone mineral density (BMD).
The history of BMD measurement dates back to the 1940s. At that time, bone density was measured on plain radiographs (X-rays). However, because loss of bone density is not apparent on a plain X-ray until approximately 40% of the bone is lost, different methods of BMD measurement have been developed.
In the early 1960s, a new method of measuring BMD, called single-photon absorptiometry (SPA), was developed. In this method, a single-energy photon beam is passed through bone and soft tissue to a detector. The amount of mineral in the path is then quantified. The distal radius (wrist) is usually used as the site of measurement because the amount of soft tissue in this area is small.
SPA measurements are accurate, and the test usually takes about 10 minutes. The radioactive source gradually decays, however, and must be replaced after some time.
Dual-photon absorptiometry (DPA) uses a photon beam that has two distinct energy peaks. One energy peak is absorbed more by the soft tissue. The other energy peak is absorbed more by bone. The soft-tissue component is subtracted to determine the BMD.
DPA allowed for the first time BMD measurements of the spine and proximal femur. However, although DPA is accurate for predicting fracture risk, the precision is poor because of decay of the isotope. In addition, the machine has limited usefulness in monitoring BMD changes over time.
Dual-energy X-ray absorptiometry (DXA) works in a similar fashion to DPA, but uses an X-ray source instead of a radioactive isotope. This measurement technique is superior to DPA because the radiation source does not decay and the energy stays constant over time. DXA has become the "gold standard" for BMD measurement today.
Scan times for DXA are much shorter than for DPA, and the radiation dose is very low. The skin dose for an anteroposterior spine scan is in the range of 3 mrem.
DXA scans are extremely precise. Precision in the range of 1% to 2% has been reported. DXA can be used as an accurate and precise method to monitor changes in bone density in patients undergoing treatments.
The first generation DXA machines used a pencil beam-type scanner. The X-ray source moved with a single detector. Second-generation machines use a fan-beam scanner that incorporates a group of detectors instead of a single detector. These machines are considerably faster and produce a higher resolution image.
Measurement of BMD by quantitative computed tomography (QCT) can be performed with most standard CT scanners. QCT is unique in that it provides for true three-dimensional imaging and reports BMD as true volume density measurements.
The advantage of QCT is the ability to isolate an area of interest from surrounding tissues. QCT can, therefore, localize an area in a vertebral body of only trabecular bone, leaving out the elements most affected by degenerative change and sclerosis.
The radiation dose with QCT is about ten times that of DXA, and QCT tests may be more expensive than DXA.
Lower cost portable devices that can determine BMD at peripheral sites such as the radius, phalanges, or calcaneus are increasingly being used for osteoporosis screening. The advantage of using a portable device is the ability to bring BMD assessment to a population who otherwise would not be able to have the test. These machines are considerably less expensive than those that measure BMD in the hip and spine.
One of the problems with peripheral testing is that only one site is tested; thus, low bone density in the hip or spine may be missed. This may be a problem because of differences in bone density between different skeletal sites.
Although peripheral machines are considered accurate, doubts have been raised about their precision. Peripheral machines may not be good enough to monitor patients undergoing treatment for osteoporosis.
In postmenopausal women, differences in BMD between different skeletal sites is more common. BMD may be normal at one site and low at another site. In the early postmenopausal years, bone density in the spine decreases first because the bone turnover in this highly trabecular bone is greater than at other skeletal sites. Bone density becomes similar across the skeleton at approximately 70 years of age.
In early postmenopausal women--therefore, up to the age of 65 years--the most accurate site to measure BMD is probably the spine. In women older than 65 years, BMD is similar across the skeleton; therefore, it may not make much difference which site is measured.
Caution must be used when interpreting spine scans in elderly patients because degenerative changes may falsely elevate BMD values. BMD measurements are, however, mostly site specific, and the most accurate predictor of fracture risk at any site is a BMD measurement of the spine.
At present, peripheral BMD testing machines are good screening devices because of their portability, availability, and lower cost. However, the following patients may still need central testing, even if peripheral testing is normal:

• Postmenopausal patients not on hormone replacement therapy (HRT) who would consider HRT, bisphosphonates, or selective estrogen receptor modulators (SERMs), if low bone mass is discovered
• Patients with a maternal history of hip fracture, smoking, tallness (more than 5' 7") or thinness (less than 125 lb)
• Patients on medications associated with bone loss
• Patients with secondary conditions associated with low bone mass, such as hyperthyroidism, posttransplantation, malabsorption, hyperparathyroidism, and alcoholism
• Patients found to have high urinary collagen crosslinks
• Patients with a history of previous fragility fracture

The main purpose of obtaining a bone density test is to determine fracture risk. BMD correlates very well with risk of fracture. It is more powerful in predicting fractures than cholesterol is in predicting myocardial infarction or blood pressure in predicting stroke.

If you have osteoporosis and you fall, you are likely to break a bone.
More than ten million people currently have osteoporosis; another 34 million have low bone mass and therefore are at risk of developing the disease. More than 2 million Americans sustain a fracture related to osteoporosis each year.
Bone is a living tissue composed mainly of calcium and protein which provide strength. Bone is constantly reforming (remodeling) as calcium is added to your bones and absorbed by your body.
Osteoporosis or "porous bone" develops when bone calcium is no longer replaced as quickly as it is removed, making the bone brittle. Half of all women over 50 will sustain an osteoporosis-related fracture sometime in their life. Men account for 20 percent of those affected by osteoporosis.
Factors that contribute to osteoporosis are:

• Aging
• Lack of weightbearing exercise
• Excessive thyroid or cortisone hormone
• Heredity, Caucasians and Asians are at greatest risk
• Smoking and excessive alcohol intake
• Reduced levels of estrogen after menopause
• Low calcium dietary intake, reduced calcium absorption and inadequate Vitamin D levels, which affect skeletal health.

A tumor is a lump or mass of tissue that forms when cells divide uncontrollably. A growing tumor may replace healthy tissue with abnormal tissue. It may weaken the bone, causing it to break (fracture).
Most bone tumors are noncancerous (benign). Some are cancerous (malignant).Benign tumors are usually not life-threatening. Malignant tumors can spread cancer cells throughout the body (metastasize). This happens via the blood or lymphatic system.


Cancer that begins in bone (primary bone cancer) is different from cancer that begins somewhere else in the body and spreads to bone (secondary bone cancer).
The four most common types of primary bone cancer are:
For most bone tumors, the cause is unknown.
Most patients with a bone tumor will experience pain in the area of the tumor. The pain is generally described as dull and achy. The pain may or may not get worse with activity. The pain often awakens the patient at night.
Although tumors are not caused by trauma, occasionally injury can cause a tumor to start hurting. Injury can cause a bone that is already weakened by a tumor to break. This often leads to severe pain. Some tumors can cause fevers and night sweats. Many patients will not have any symptoms, but will instead note a painless mass.
Occasionally, benign tumors may be discovered incidentally when X-rays are taken for other reasons, such as a sprained ankle or rotator cuff problem.
If you think you might have a bone tumor, see your doctor as soon as possible for diagnosis and treatment.
Occasionally, infection, stress fractures, and other non-tumor conditions can closely resemble tumors.
Your doctor will collect detailed information about your general health and the tumor's type, size, location, and possible extent of spread.
When treatment for a bone tumor is finished, the doctor may take more x-rays and other imaging studies. These can confirm that the tumor is actually gone. Regular doctor visits and tests every few months may be needed. When the tumor disappears, it is important to monitor your body for signs that is may have returned (relapse).
Genetic research is leading to a better understanding of the types of bone tumors and their behaviors. Researchers are studying the design of metallic implants. This allows better function and durability after limb salvage surgery.
Advancements in the development of prosthetic limbs include computer technology. This is leading to better function and quality of life after amputation.
Research into new medications and new combinations of older medications will lead to continual improvements in survival from bone cancers. Your doctor may discuss clinical research trials with you. Clinical trials may involve the use of new therapies and may offer a better outcome.