A.

Physiology Formula for Glucose:

Plasma glucose (P) – synovial fluid (SF) glucose
Synovial joints or movable joints (diarthroses)

Synovial membrane - contains Grading/Reporting:

specialized cells called synoviocytes Good – solid clot
Fair – Soft clot
Low – Friable clot
Poor – No clot

Notes to Remember:
o Arthritis affects both the production of hyaluronate
and its ability to polymerize; decreased (↓)
polymerization, thus decreasing the fluid viscosity
Synovial / Synovium – “egg” Lactate <250 mg/dL (↓). Failure to form string (Viscosity)
or “egg white” Uric acid equivalent to plasma values o
Hyaluronate 0.3 – 0.4 g/dL

 Imperfect ultrafiltrate of plasma less than < 3.5 mL of B. Gross Examination

volume containing hyaluronic acid and small amount of proteins
produced by synoviocytes  Upon closer look, normal viscous synovial fluid resembles
egg white.
Synoviocytes secrete a mucopolysaccharide containing
hyaluronic acid (large hyaluronate molecules contribute the C. Chemical Examination
1. Color
noticeable viscosity to the synovial fluid) a. Normal: colorless to pale yellow
b. Variations:
FUNCTIONS OF SYNOVIAL FLUID o Yellow - Green (septic)
1. Lubricates 3. Provides nutrients o Red - Brown (hemorrhagic)
o Deep yellow (inflammatory &
2. Reduces friction 4. Lessens shock and joint compression <250 mg/dL
noninflammatory)
2. Clarity Equivalent to
Damage to the articular membranes produces pain and plasma values
stiffness in the joints, collectively referred to as arthritis. a. Normal: clear
b. Variations:
Arthro - indicates a jointed appendage of the body; joint o Turbid (leukocytes, fibrin, rice bodies,
-itis - means “inflammation.” cartilage fragments)
o Milky (crystal induced)
Provide most of the inflammatory processes that require medical o Ground pepper (metabolic disorder)
intervention:
3. Viscosity
 Knee Hip a. Falling drop – ability to form a string 4 – 6 cm long
 Shoulder ankle b. Ropes/Mucin clot test
 Wrist 2 % or 5 % acetic acid added to fluid
Formation of clot is observed

D. Specimen Consideration
Specimen Collection
 Arthrocentesis is performed by inserting a sterile needle
into the joint space of the involved joint to obtain synovial fluid
for analysis.
 Aspiration (withdrawal of the fluid) may be performed on
any major joint as mentioned above.
 Tubes and tests performed
1. Sterile heparinized tube (yellow) – Gram stain and
culture (MICROBIOLOGY)
2. Sodium heparin or liquid EDTA tube (lavender) – cell
counts (HEMATOLOGY)
3. Nonanticoagulated tube (red) – chemical and serologic
tests (CHEMISTRY)
4. Sodium fluoride tube (gray) – glucose analysis
(CHEMISTRY)
Tests most frequently performed on synovial fluid are:
White blood cell (WBC) count
Differential
Gram stain and culture
Crystal examination
Procedure:
Practice of standard precautions is to be followed to prevent
transfer of infectious organisms during the collection of fluid. In a
manner akin to that of collecting and transporting cerebrospinal
fluid, the fluid is divided into three tubes if the volume is sufficient.
o A sterile tube is used for microbiological tests, and if
possible, a 5 or more mL sample is placed in this tube.
o For the determination of the presence of blood cells and
crystals, 5 mL of an anticoagulant to prevent clotting and
clumping of any cells in the fluid is placed into a tube
containing sodium heparin, the anticoagulant most
commonly used for this procedure. The heparin solution
prevents clotting by interfering with the coagulation
factors that may be present in the fluid. The cell count can
then be more easily performed and serves to preserve the
cellular morphology of both white and red blood cells that
may be present in the fluid.
o Other anticoagulants such as oxalates and powdered
EDTA, as well as lithium heparin, are sometimes used but
may result in crystallization of the additives. When this
phenomenon occurs, it could potentially give confusing
information that may be interpreted as the presence of
crystals that are contributing to an inflammatory process.
Liquid EDTA is preferred.
o Chemical and immunological tests require a red-topped
tube in which clotting can take place, if possible. Normal
synovial fluid will not clot, but the effusion of blood with
its coagulation factors may cause a clot to occur. After
centrifugation of the sample, the clear portion of fluid in
which the clot occurs (serum) may be used for chemistry
tests, such as for glucose.
E. Microscopic Examination
Notes to Remember:
Patients should be fasting a minimum of 4 to 6
hours, usually 8 hours to allow for the equilibration of
chemical constituents between plasma and synovial fluid.
A blood sample is collected at approximately the
same time (simultaneously) as the arthrocentesis procedure
is performed when determination of the plasma–synovial
fluid difference in glucose is requested.
To prevent falsely decreased values caused by
glycolysis, specimens should be analyzed within 1 hour or
preserved with sodium fluoride.
Crystal examination should be performed soon after
fluid collection to ensure that crystals are not affected by
changes in temperature and pH. Both MSU and CPPD crystals
are reported as being located extracellularly and
intracellularly (within neutrophils); therefore, fluid must be
examined before WBC disintegration.

1. WBC count (Manual Cell Counts)
- most frequently performed counts.
Does not use WBC diluting fluid; it can form mucin clots
Reagents:
 Normal Saline Solution (NSS) with methylene blue
 Hypotonic saline 0.3%
 Saline with Saponin
2. Differential count
Pinch of hyaluronidase is added to a 0.5 mL of synovial
fluid
1 drop of 0.05% hyaluronidase in phosphate buffer per mL
of fluid. Incubate at 37 C for 5 minutes
o To eliminate the potential for clot formation and
reduce the viscosity of synovial fluid, before
analysis a well-mixed portion is transferred to
another tube and a few grains of hyaluronidase
are added. This enzyme will eliminate
hyaluronate, thereby preventing clot formation,
reducing viscosity, and enhancing an even
distribution of cells in the counting chambers of
the hemacytometer.
o When the fluid requires dilution because it is
cloudy or turbid, a hyaluronidase buffer solution
can be used as the diluent.
Cytocentrifugation (recommended)
Neubauer counting chamber
1.) Why should synovial fluids be less viscous when
performing in automated cell counters?
Highly viscous fluid may block the apertures, and
the presence of debris and tissue cells may falsely elevate
counts. Therefore incubation of the fluid wit hyaluronidase
must be done in order to decrease the specimen viscosity.
2.) Why should we have to stain our sample with
methylene blue?
To accurately identify mononuclear and
polymorphonuclear cells. Your WBCs are mostly
distinguished by the appearance of there nuclei. A stained
smear in hemacytometer is necessary for accurate
differentiation of cells.
3.) What actions should be taken if a medical
technologist receives a turbid or bloody synovial fluid
specimen?
Pretreat the sample with a hyaluronidase and
incubate at 37 C for 5 minutes. Then perform slide prep for
Neubaurer counting by using NSS with methylene blue for
CLEAR SPECIMENS. However, for TURBID or BLOODY
specimens, lyse the intact RBCs. Hypotonic saline (0.3%) or
saline that contains saponin is preferred or used.
4.) Why Leukocyte count/WBC count the most frequently
performed cell count on synovial fluid?
Most frequently performed cell count because
most diseases affected in the synovial fluid are associated
with WBCs. For crystal identification, crystals (MSU) and
(CPPD) are located extracellularly or intracellularly in
neutrophils. Thus synovial fluid must be examined
immediately (STAT) before any WBC disintegrate.
5.) What steps should be taken for patients when glucose
determination of synovial fluid specimens is ordered by
the physician?
The patient should fast at least 8 hours prior to
extraction. There are 2 extractions performed.
A blood sample is drawn from the patient for
plasma glucose test. This happens approximately the same
time as the arthrocentesis procedure is being performed.
To calculate the glucose:
Plasma glucose (P) - Synovial fluid glucose (SF) =
should be ‹10 mg/dL (NORMAL)
6.) What should be done to prevent specimens in
synovial fluid to falsely decrease its glucose values?
Specimens should be analyzed within 1 hour or
should be preserved with sodium fluoride (gray stoppered
tubes).
7.) The tubes that are commonly used for synovial fluid
specimens in various sections of the lab are:
1. Sterile heparinized tube (yellow) – Gram stain and culture
(MICROBIOLOGY)
2. Sodium heparin or liquid EDTA tube (lavender) – cell counts
(HEMATOLOGY)
3. Nonanticoagulated tube (red) – chemical and serologic tests
(CHEMISTRY)
4. Sodium fluoride tube (gray) – glucose analysis (CHEMISTRY)
8.) Why is Liquid EDTA preferred over powdered EDTA in
specimen collection for synovial fluid?
Powdered EDTA may result to crystallization of
additives. It might confuse and interpret the presence of crystals
that are contributing to an inflammatory process
9.) How can we permit better differential diagnosis
between gout and pseudogout?
Calcium pyrophosphate dihydrate (CPPD) of
pseudogout are positive (+) birefringent [blue on red
background] and perpendicular to axis.
Monosodium urates (MSU) of Gout are negative
(-) birefringent [Yellow on red background] and parallel to
axis
These crystal examination is done under compensated
polarized light.
10.) Why should sodium heparin or liquid EDTA the
anticoagulant of choice for synovial fluid specimens?
They do not form crystals. Thus they do not
interfere with microscopic examination of crystals.
Note that anticoagulant-associated crystals (e.g., calcium
oxalate, powdered EDTA) can also be phagocytosed by
WBCs after collection and storage. Crystals are associated
with WBCs, specifically neutrophils.
11.) What should be observed in the laboratory results
when the patient has septic arthritis?
Chemical examination/Chemistry:
Lactate is increased
Glucose is decreased
Total protein (not routinely performed) > 3g/dL
Microscopic examination/Hematology:
WBC count is 50-100,000/uL
Polymorphonuclear cells PMNs/Neutrophils >75%
Presence of Rice bodies
Microbiology:
(+) for gram stain
Physical examination:
Yellow - Green tinge (color) of specimen
Viscosity is variable
Clarity is turbid
12.) Should synovial fluid specimens be refrigerated if
processing is delayed?
Refrigeration adversely affects the viability of
microorganisms and could induce vitro crystalline
precipitation.
Synovial fluid should be transported and analyzed
at room temperature. As with other body fluids, it should
be processed and tested as soon as possible after
collection.
13.) When the cell count is below 200/μL, and fewer than
25% of the cells are Polymorphonuclear (segmented
neutrophils), and no red cells are observed, the count
is???
NORMAL
14.) What normal cells are found in synovial fluid?
(Hematology/Microscopic examination)
Monocytes, lymphocytes and macrophages are normally
seen in small numbers in the absence of a disease process.
Synovial tissue cells are also present followed by
arthrocentesis.
15.) In terms of slide preparation, what is the main
difference between WBC count and Crystal examination?
For crystal identification, initial examination is
WET PREP, UNSTAINED, under LOW and HIGH power,
viewed under Bright field microscopy.
This means that a drop of the same fluid is directly placed
on a pre cleaned glass slide and is covered with a cover
slip.
For WBC counting, the specimen is thoroughly
mixed or prepared using the Neubaurer counting chamber,
before STAINED with methylene blue under LOW and
HIGH power fields. Bright field microscopy
16.) Why should synovial specimens contained in non-
anticoagulated tubes be centrifuged?
They must be centrifuged to separate cellular
elements from interfering with chemical or serologic
analyses.
20.) What cells are normally found on synovial
17.) What is the purpose of NSS?
fluid?
To preserve the morphology and prevent distortion of the White blood cells called mononuclear cells
cells.
include lymphocytes, monocytes, macrophages, and
18.) Differentiate Septic arthritis from Degenerative synovial tissue cells are the primary cells that will be
arthritis. seen in normal synovial fluid.
21.) Cell counts for both red and white blood cell
counts are performed on synovial fluid only in what
condition?
Only when the blood in the specimen is
19.) What are other disease that affect the synovial? known to be the result of a traumatic tap or
hemarthrosis (bleeding into a joint). The color of the
fluid would be red-brown.
22.) Why counts for both red and white blood cells
should be performed immediately (STAT)?

Polymorphonuclear segmented neutrophils

(PMNs), a type of white blood cell known to be
elevated in most cases of bacterial infection, will
decrease rapidly after 1 h.

23.) The swelling of a joint or joints usually signals

an increase in what fluid?

An increase in fluid (edema) accumulates

around the inflammatory site to combat an infection.