Chapter Outline

Physiology and Composition of Synovial Fluid

Specimen Collection

Laboratory Testing
Macroscopic Evaluation
Chemical Examination
Microscopic Examination

Classification of Joint Disorders


Synovial Fluid
Synovial
syn(like) + ovia (egg)

Joint Fluid







Synovial Fluid
Viscous fluid found in the
cavities of movable joints
(diarthroses)

Synovial membrane
Inner membrane of
synovial joints
Secretes synovial fluid
into the joint cavity
Contain specialized cells
(synoviocytes)
Composition
Hyaluronic acid
synthesized by the synovial membrane
increase the viscosity and elasticity of articular
cartilages
lubricate the surface between synovium and
cartilage.

Lubricin secreted by synovial cells.

It is chiefly responsible for so called boundary
layer lubrication, which reduces friction between
opposing surfaces of cartilage.

What do you call the damage to
the articular membranes
producing stiffness and pain in
the joints?


Major Functions
Reducing friction
Lubrication
Lessen shock
Supplying oxygen and
nutrients


Synovial Fluid:
Specimen Collection

Bulge test
The Bulge test is used to determine if there is an
abnormal amount of fluid surrounding a joint
Bulge test of joint for the detection of synovial effusion
Bulge Test

Specimen Collection
Arthrocentesis

Placement of needle in arthrocentesis of (A) elbow and
(B) knee joints.
Macroscopic Laboratory Testing
Volume
Color and Clarity
Inclusions
Viscosity
Clotting
Mucin Clot


Laboratory Testing: Macroscopic
Volume

Normal up to <3.5 ml of fluid

Can reach up to 25 ml
Inflammation



Macroscopic Analysis: Color and Clarity
Colorless to pale yellow and clear
normal
Red, brown, or xanthochromic
hemorrhage into the joint
Yellow/clear
noninflammatory effusions
Yellow/cloudy
inflammation
White/cloudy/milky
Crystals
Deeper yellow
Non inflammatory and inflammatory effusions

Macroscopic Analysis: Inclusions
Rice bodies.
Free-floating aggregates of tissue appear as
rice bodies.
rheumatoid arthritis (RA)
Degenarated synovium enriched with
fibrin

Ochronotic shards
debris from joint prosthesis
look like ground pepper



A =ochronotic shards

B =rice bodies

Macroscopic Analysis: Viscosity
Ropes or Mucin Clot
Test
Normal = 4-6 cm

When 2-5% acetic acid
is added, normal
synovial fluid will form
a clot surrounded by
clear fluid

A medical technologist received 2 clear,
thick and viscous samples labelled A
and B. He added 2% acetic acid, sample
A did not clot while sample B did.
Which of the following is suggestive of
synovial fluid? The other sample may
possibly be?
When sufficient blood is collected,
it should be distributed in what
color of tubes?
Sterile heparinized = GS/CS
Heparin / EDTA = cell count
Noncoagulated tube = other tests
Sodium fluoride = Glucose
Macroscopic Analysis: Clotting
Normal synovial fluid: Do not clot
Clotting of synovial fluid = fibrinogen


1.Damaged synovial membrane
2.Traumatic tap

Macroscopic Analysis: Mucin Clot
Ropes test

Estimation of hyaluronic acid
protein complex integrity

The adding of acetic acid to
normal synovial fluid, which
causes clot formation.

Criteria:
Compactness of the clot
Clarity of the supernatant fluid


Mucin Test
Good : solid clot
Fair: soft clot
Low: Friable clot
Poor: No clot
Macroscopic Analysis: Cell Counts
Total leukocyte count
<200 cells/uL

Very viscous fluid
Pinch of hyaluronidase + 0.5 ml fluid
1 gtt 0.05% hyaluronidase in phosphate buffer per ml of
fluid (incubate 37oC for 5 minutes)
Macroscopic Analysis: Cell Counts
Diluents:
Saline
0.3% hypotonic solution
Saline that contains saponin

Why is the traditional WBC fluid
not used for cell counting?
Because it contains
______________ which is
responsible for clotting.

Can clear undiluted fluid be
used for counting?
Macroscopic Analysis: Cell
Counts
Neubauer Counting Chamber

Macroscopic Analysis: Diff Count
Incubate with hyaluronidase
Neutrophils : <25% of the differential
Lymphocytes: <15%
Crystal: None present

Increase neutrophil: septic condition
Increase cell count with increase lymphocyte:
nonseptic inflammation
Chemical Analysis: Protein
All proteins found in plasma

Exception: various highmolecular weight proteins
which may be present in very small amount

Fibrinogen

beta 2 macroglobulin

alpha 2 macroglobulin

Use common serum protein procedures

Chemical Analysis: Protein (cont.)
Normal range <3 g/dl

Increased protein

ankylosing spondylitis

arthritis

Crohn disease

Gout

Psoriasis

Reiter syndrome

ulcerative colitis.

Chemical Analysis: Glucose
Compare to serum glucose levels

<10 mg/dL lower than blood glucose

Decreased joint disorders

>20mg/dl decrease - infection

Chemical Analysis: Uric Acid
Normal - 6 to 8 mg/dL

Increased gout

May form crystals

Chemical Analysis: Lactic Acid
Rarely measured in synovial fluid

Can be helpful in diagnosing septic arthritis.

Normal = less than 25 mg/dL

Septic arthritis can show levels up to 1000 mg/dL

Laboratory Testing: Lactate Dehydrogenase
Elevated in synovial fluid
Normal in serum level

Increased in
Rheumatoid arthritis
(RA)
infectious arthritis
gout

Neutrophils increased
during the acute phase of
these disorders contribute
to this increased LD.

Laboratory Testing: Rheumatoid Factor
RF is an antibody to immunoglobulins.

Present in rheumatoid arthritis:

Serum most cases

Synovial fluid - 50%

Rarely elevated only in synovial fluid and not
serum

False positives in other chronic inflammatory
diseases.

Microscopic Analysis: Differential
LE cells
Neutrophils that have
engulfed a nucleus of a
lymphocyte

Tart cells
Monocytes that have
engulfed nuclear
material
Microscopic Analysis: Differential
Reiter cells
Vacuolated macrophages
with ingested neutrophils

RA cells
Ragocytes
Neutrophils with small,
dark, cytoplasmic
granules that consist of
precipitated rheumatoid
factor
Microscopic Analysis: Differential
Hemosiderin
Seen in Pigmented
Villonodular Synovitis
Inclusions within clusters
of synovial cells
Rice bodies
Macroscopically resemble
polished rice
Macroscopically show
collagen and fibrin
Microscopic Analysis: Differential
Fat droplets
Refractile intracellular and
extracellular globules
Stain with Sudan Dye

Crystal Identification
Monosodium urate (MSU)



Calcium pyrophosphate (CPPD)



Crystal Identification

Corticosteroid



Cholesterol


Crystal Identification
Calcium oxalate




Apatite (Ca Phosphate)
Laboratory Testing: Microbiology
Staining

Smears prepared by centrifugation or
cytocentrifugation
Saline dilution reduces clustering of cells
Grams stain most common

Culture

Set up with positive or negative stain results
Aerobic
anaerobic
Classification of Joint Disorders
Classification of Joint Disorders
Group Classification Pathologic Significance
1. Noninflammatory Degenerative joint
disorders, osteoarthritis
2. Inflammatory Immunologic Disorders,
RA, LE, Scleroderma,
Polymyositis, ankylylosing
spondylitis, rheumatic
fever, Lyme arthritis,
Crystal-induced gout,
pseudogout
Classification of Joint Disorders
3. Septic Microbial Infection

4. Hemorrhagic Traumatic injury, tumors,
hemophilia, other coagulation
disorders, anticoagulant overdose
Laboratory Findings
1. Noninflammatory
Clear, yellow fluid
Good viscosity
WBCs <1000 uL
Neutrophils <30%
Normal glucose (similar to blood glucose)
Laboratory Findings
2. Inflammatory
Immunologic origin Crystal - induced
Cloudy, yellow fluid Cloudy, yellow fluid
Poor viscosity Low viscosity
WBCs 2,000 75,000 uL up to 100,000 uL
Neutrophils >50% <70%
Decrease glucose level Decreased glucose level
autoantibodies present Crystals present

Laboratory Findings
3. Septic
Cloudy yellow-green fluid
Variable viscosity
WBCs 50,000 100,000 uL
Neutrophils > 75%
Decreased glucose level
Positive culture and gram stain

Laboratory Findings
4. Hemorrhagic
Cloudy, red fluid
Low viscosity
WBCs equal to blood
Neutrophils equal to blood
Normal Glucose level
Review of Key Points
Synovial fluid analysis
Is a well-established procedure for evaluation of joint
disease.
Determines the presence of arthritis
Assists in the classification of joint disorders
Helps guides appropriate treatments


Thank you