Synovial Fluid

Physiology
Synovial Fluid

Joint Fluid
Viscous liquid found in the cavities of the movable joints (diarthroses) or synovial joints
o Bones in synovial joints lined with smooth articular cartilage and separated by a
cavity containing the synovial fluid
o Synovial membrane contains synoviocytes (lines joints)
o Smooth articular cartilage and Synovial Fluid reduce friction between bones
during joint movement
Formed as an ultrafiltrate of plasma across the synovial membrane
o Filtration is nonselective except for the exclusion of high-molecular-weight
proteins
o Some of the constituents have similar concentration to plasma values (glucose,
uric acid)
Provide nutrients for the vascular-deficient cartilage
Lubrication in joints
Provides nutrients to the articular cartilage
Lessens the shock of joint compression during activities (eg, walking, jogging)
Synoviocytes secrete a mucopolysaccharide containing hyaluronic acid and a small
amount of protein (1/4 of plasma concentration) into the fluid
Large hyaluronate molecules contribute the noticeable viscosity to the synovial fluid
Arthritis damage to the articular membranes produces pain and stiffness in the joints
o Associated with arthritis:
Infection
Metabolic disorders
Trauma
Physical stress
Advanced age
Beneficial Tests Most Commonly Performed on Synovial Fluid
o WBC count
o Differential
o Gram stain
o Crystal Examination

Normal Synovial Fluid Values

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Volume
Color
Clarity
Viscosity
Leukocyte count
Neutrophils
Crystals
Glucose: plasma difference
Total Protein

<3.5 mL
Colorless to pale yellow
Clear
Able to form a string 4-6 cm long
<200 cells/L
<25% of the differential
None present
<10 mg/dL lower than the blood glucose level
<3 g/dL

Classification and Pathologic Significance of Joint Disorders

Group Classification
Pathologic Significance
I.
Non-inflammatory
Degenerative Joint Disorders
Osteoarthritis
II.
Inflammatory
Ankylosing spondylitis
Immunologic disorders
Lyme arthritis
Polymyositis
Rheumatoid arthritis
Rheumatic Fever
Scleroderma
Systemic Lupus erythematosus
III.
Septic
Microbial Infection
IV.
Hemorrhagic
Anticoagulant overdose
Hemophilia
Traumatic injury
Tumors
Other coagulation disorders

Group Classification
Noninflammatory

Inflammatory
Immunologic Origin

Laboratory Findings in Joint Disorders

Laboratory findings
Clear yellow fluid
Good viscosity
WBCs <1,000 L
Neutrophils <30%
Similar to blood glucose
Cloudy, yellow fluid
Poor viscosity
WBCs 2,000 to 75,000 L
Neutrophils >50%
Decreased glucose level
Possible autoantibodies present

Crystalpinduced origin

Septic

Hemorrhagic

Cloudy or milky fluid

Low viscosity
WBCs up to 100,000 L
Neutrophils <70%
Decreased glucose level
Crystals present
Cloudy, yellow-green fluid
Variable viscosity
WBCs 50,000 to 100,000 L
Neutrophils >75%
Decreased glucose level
Positive culture and Gram-stain
Cloudy, red fluid
Low viscosity
WBCs equal to blood
Normal glucose level

Specimen Collection and Handling

Collected by needle aspiration called arthrocentesis

Amount of fluid present varies with the size of the joint and the extent of the fluid buildup
in the joint
The volume of fluid collected should be reported
Normal synovial fluid does not clot
Fluid from diseased joint may contain fibrinogen and will clot
Fluid is collected in a syringe moistened with heparin
Specific tubes based on required test:
o Nonanticoagulated or Plain Tube For Chemistry and Immunology
o Heparin or liquid EDTA Cell counting
o Sterile with anticoagulant (Sterile heparinized or Sodium polyanethol sulfonate)
- Microbiologic exam (Gram Stain and culture)
o Sodium fluoride Glucose analysis
Powdered anticoagulants should not be used may produce artifacts that interfere with
crystal analysis
Nonanticoagulated tubes should be centrifuged and separated to prevent cellular
elements from interfering
Handled like STAT specimens
o To avoid alterations of chemical constituents
o Cell lysis
o Problems in identification of microorganisms

Color and Clarity

Normal colorless to pale yellow

3

Synovial Latin word egg = ovum

Deeper yellow presence of noninflammatory and inflammatory effusions
Greenish Tinge bacterial infection
Red or Brown or Xanthochromic traumatized during arthrocentesis and haemorrhage
Milky Tuberculous arthritis or when crystals are present
Turbidity presence of WBCs
o Synovial cell debris and fibrin can also produce

Viscosity

Very viscous
Comes from polymerization of hyaluronic acid and is essential for the proper joints
lubrication
Arthritis affects production of hyaluronate = Viscosity
Forming a string on the tip of the syringe - 4 to 6 cm
Ropes or Mucin Clot Test (2 5% acetic acid)
o Measures hyaluronate polymerization
o Forms a solid clot surrounded by clear fluid
o Hyaluronate polymerization = Clot less firm = Turbidity of surrounding fluid
o Reported in terms of:
Good solid clot
Fair soft clot
Low friable clot
Poor no clot
Formation of mucin clot after adding acetic acid can identify a questionable fluid as
synovial fluid

Cell Counts

Total Leukocyte Count most frequently performed

Normal WBC count - <200 WBCs/L
Severe infections - >100,000 WBCs/L
Septic and inflammatory forms of arthritis considerable overlap of elevated leukocyte
counts
Counts should be performed ASAP or refrigerate the specimen to prevent cellular
disintegration
Very viscous fluid pretreated by adding 1 drop of 0.05% hyaluronidase in phosphate
buffer per mL of fluid and incubating at 37C for 5 minutes
Manual Counts Neubauer Counting Chamber
Automated Cell counters
Clear fluids counted undiluted
Turbid or Bloody fluids dilutions necessary
Normal Saline used as diluent
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Hypotonic saline (0.3%) or saline with saponin diluent to lyse RBCs

Methylene Blue + NSS stains WBC nuclei, permits separation of WBCs and RBCs
during counts
Recommended technique line a petri dish with moist paper and place hemocytometer
on 2 small sticks to elevate it above the moist paper. Fill and count both sides of the
hemocytometer.
Counting procedure:
o <200 WBCs/L count all 9 large squares
o >200 WBCs/L in the above count count 4 corner squares
o >200 WBCs/L in the above count count 5 small squares used for RBC count

Differential Count

Should be performed on cytocentrifuged preparations or on thinly smeared slides

Fluid should be incubated with hyaluronidase prior to slide preparation
Primary cells in normal SF
o Monocytes
o Macrophages
o Synovial tissue cells
Neutrophils - <25%
Increased neutrophils in differential count septic condition
Lymphocytes - <15%
Increased lymphocytes nonseptic inflammation
Presence of other cell abnormalities:
o Eosinophils
o LE cells
o Reiter cells (neutrophages macrophages w/ ingested neutrophils)
o RA cells (ragocytes PMN w/ small, dark, cytoplasmic granules)
Lipid droplets present after crush injuries
Hemosiderin granules seen in pigmented villonodular synovitis
Inclusions:
o Rice bodies free floating aggregates of issue
o Ochronotic shards debris from metal joint prosthesis which look like ground
pepper

Cells and Inclusions Seen in Synovial Fluid

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Cell/Inclusion
Neutrophil

Description
Polymorphonuclear leukocyte

Lymphocyte
Macrophage (Monocyte)

Mononuclear leukocyte
Large mononuclear leukocyte
May be vacuolated
Similar to macrophage, but
may be multinucleated
Resembling a mesothelial cell
Neutrophil containing
characteristic ingested round
body
Vacuolated macrophage with
ingested neutrophils
(Neutrophil-laded
macrophage)
Neutrophil with dark
cytoplasmic granules
containing immune complexes
Large, multinucleated cells
Macroscopically resemble
polished rice
Microscopically shown
collagen and fibrin
Refractile intracellular and
extracellurar globules
Stain with Sudan dyes
Inclusions within clusters of
synovial cells

Synovial Lining Cell

LE cell

Reiter Cell

RA cell (Ragocyte)

Cartilage cells
Rice Bodies

Fat Droplets

Hemosiderin

Significance
Bacterial sepsis
Crystal-induced inflammation
Nonseptic Inflammation
Normal
Viral infections
Normal
Disruption from arthrocentesis
Lupus erythematosus
Seen in 10% of patients with
SLE
Reactive arthritis (infection in
another part of the body)

Rheumatoid arthritis
Immunologic inflammation
Osteoarthritis
Tuberculosis
Septic and rheumatoid
arthritis
Traumatic injury
Chronic inflammation
Pigmented villonodular
synovitis

Crystal Identification

Important diagnostic test in evaluating arthritis

Crystal formation in joint acute, painful inflammation chronic condition
Causes of crystal formation:
o Metabolic disorders
o Decreased renal excretion

Types of Crystals
Monosodium urate or Uric Acid or MSU
o Primary crystals seen in SF
o Gout, Calcium Pyrophosphate Dihydrate (CPPD), Pseudogout
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 Causes of Gout
o Increase in serum uric acid resulting from impaired metabolism of purines
o Increased consumption of high-purine-content foods, alcohol and fructose
o Chemotherapy treatment of leukemias
o Decreased renal excretion of uric acid
Pseudogout
o Associated woth degenerative arthritis, producing cartilage calcification and
endocrine disorders, producing elevated serum calcium levels
Hydroxyapatite (Basic Calcium Phosphate)
o Calcium degeneration, cholesterol crystals associated with chronic inflammation,
corticosteroids after injections, calcium oxalate crystals (renal dialysis pxs)
Patients history must always be considered
Artifacts:
o Talcum powder and starch from gloves, precipitated anticoagulants, dust, and
scratches n slides and cover slips
Crystal
Monosodium Urate

Characteristics of Synovial Fluid Crystals

Shape
Compensated
Polarized Right
Needles
Negative
Birefringence

Calcium
Pyrophosphate

Rhomboid square,
rods (short)

Positive Birefringence

Cholesterol

Notched, Rhomboid
plates
Flat, variable-shaped
plates
Envelopes

Negative
Birefringence
Positive and Negative
Birefringence
Negative
Birefringence
No Birefringence

Corticosteroid
Calcium Oxalate
Apatite (Calcium
Phosphate)

Small particles
Require electron
microscopy

Significance
Gout
Extra/Intracellular
(sticking through
cytoplasm of PMNs)
Pseudogout
(w/in vacuoles of
PMNs)
Extracellular
Injections
Renal dialysis
Osteoarthritis

Slide Preparation
Crystal examination should be performed after fluid collection to ensure crystals are not
affected by changes in temperature and pH
MSU & CPPD reported as being located intracellularly or extracellularly (within PMNs)
o Examined before WBC disintegration
Fluid is examined as an unstained wet preparation
One drop of fluid is placed on a precleaned glass slide and cover slipped
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Examined in LPO and HPO using a regular light microscope

Crystals observed in Wright-stained smears
MSU lyse phagosome membranes do not appear in vacuoles
Red Compensated Polarized Microscopy used to avoid misidentification of CCPD

Crystal Polarization
Direct polarization determine presence of crystals
First order Red Compensated Polarized Microscopy used for positive identification
Tamethasone acetate corticosteroid used to prepare control slide for polarization
properties of MSU
Red compensator
o Separates light ray into slow-moving and fast-moving vibrations & produces a red
background
o Placed in microscope between crystal and analyser
When crystals are aligned perpendicular to slow vibration, color is reversed
MSU
Ability to polarize light
More highly birefringent & appears brighter
against dark background
Run parallel to the long axis of the crystal

CPPD
Ability to polarize light

When aligned with the slow vibration:

Velocity of slow light passing through crystal is
not impeded as much as fast light

Run perpendicular to the long axis of the

compensator
When aligned with the slow vibration:
Velocity of fast light passing through crystal is
much quicker

PRODUCES A YELLOW COLOR

Negative Birefringence

PRODUCES A BLUE COLOR

Positive Birefringence

Chemistry Tests

Chemistry test values of SF are approximately the same as serum values

Glucose Determination most frequently requested test
o Markedly decreased glucose inflammatory (Group II) or Septic (Group III)
disorders
Normal SF values are based of blood glucose level
o Simultaneous blood and SF fluid should be obtained
o 8 hours fasting allows equilibration
Normal SF glucose not more than 10mg/dL lower than blood value
Total protein and Uric Acid Determinations large protein molecules are not filtered
o Normal protein - <3 g/dL
Presence of protein Inflammatory and hemorrhagic disorders
Uric Acid gout
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o Confirm diagnosis when presence of crystals in fluid cannot be demonstrated

Fluid lactate or ACP levels monitor severity and prognosis of rheumatoid arthritis (RA)

Microbiologic Tests

Infection secondary complication of inflammation caused by trauma or dissemination

of systemic infection
Gram stains and Culture most important tests performed on SF
Bacterial infection (frequently seen), fungal, tubercular, fungal infections special
culturing procedures should be used
Patient history & other symptoms aids in requests for additional testing
Routine bacterial cultures:
o Enrichment Medium CAP
Staph and Strep
Haemophilus spp
Neisseria gonorrhoeae

Serologic Tests

Plays important role in the diagnosis of joint disorders

Most test are performed on serum
SF analysis serves as a confirmatory test
Autoimmune diseases RA and SLE serious joint inflammation
o Presence of autoantibodies in patients serum and SF (if necessary)
Arthritis frequent complication of lyme disease
Causative agent Borrelia burgdorferi confirm cause of arthritis when demonstrated with
antibodies