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SYNOVIAL FLUID
PHYSIOLOGY Beneficial test most frequently performed
- often referred to as “joint fluid,” is a viscous on synovial fluid:
liquid found in the cavities of the movable - WBC count
joints (diarthroses) or synovial joints - differential test
- the bones in the synovial joints are lined - Gram stain
with smooth articular cartilage and separated - culture
by a cavity containing the synovial fluid. - crystal examination
- the joint is enclosed in a fibrous joint
capsule lined by the synovial membrane

Synovial membrane
- contains specialized cells called
synoviocytes

Smooth articular cartilage and synovial

fluid
- reduce friction between the bones during
joint movement

Synovial Fluid provides: Variety of Conditions associated with

- lubricants in the joints arthritis:
-provides nutrients to the articular cartilage - infection
and lessens the shock of joint compression - inflammation
- metabolic disorder
Synovial Fluid is formed: - trauma
- as an ultrafiltrate of plasma across the - physical stress
synovial membrane - advance age
- filtration is nonselective except for the
exclusion of high-molecular-weight proteins
- most of the chemical constituents, although
seldom of clinical significance, have
concentrations similar to plasma values

Synoviocytes
- cell of the synovial fluid
- secrete a mucopolysaccharide containing
hyaluronic acid and a small amount of
protein

Large Hyaluronate molecules

- contribute the noticeable viscosity to the
synovial fluid

Arthritis
- damage to the articular membranes
produces pain and stiffness in the joints
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SYNOVIAL FLUID
Consideration for amount of fluid
collected or present:
- size of the joint
- extent of fluid build up in the joint

Normal Synovial Fluid

- does not clot (fluid from a diseased joint
may contain fibrinogen and will clot)
- fluid is often collected in a syringe that has
been moistened with heparin

NOTE:
- Powdered anticoagulants should not be
used because they may produce artifacts
that interfere with crystal analysis
- The nonanticoagulated tube for other tests
must be centrifuged and separated to
prevent cellular elements from interfering
with chemical and serologic analyses
-All testing should be done as soon as
possible to prevent cellular lysis and possible
changes in crystals.

COLOR AND CLARITY

A report of the gross appearance is an
essential part of the synovial fluid analysis.

Normal synovial fluid

- appears colorless to pale yellow.

“synovial”
SPECIMEN COLLECTION AND HANDLING - comes from the latin word for egg, ovum.
Normal viscous synovial fluid
Arthrocentesis - resembles egg white
- synovial fluid is collected by needle
aspiration
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SYNOVIAL FLUID
 The color becomes a deeper yellow in essential for the proper joints lubrication
the presence of noninflammatory and
inflammatory effusions and may have Arthritis
a greenish tinge with bacterial - affects both the production of hyaluronate
infection. and its ability to polymerize, thus decreasing
the fluid viscosity
NOTE:
- As with cerebrospinal fluid, in synovial fluid
the presence of blood from a hemorrhagic Method in measuring the viscosity of
arthritis must be distinguished from blood Synovial fluid
from a traumatic aspiration. - observe the fluid’s ability to form a string
from the tip of a syringe
How?
-by observing the uneven distribution of  A string measuring 4 to 6 cm is
blood or even a single blood streak in the considered normal
specimens obtained from a traumatic Hyaluronate polymerization
aspiration - can be measured using a Ropes, or mucin
clot test.
Turbidity
- is frequently associated with the presence  When added to a solution of 2% to 5%
of WBCs. acetic acid, normal synovial fluid forms a
Also produces turbidity: solid clot surrounded by clear fluid.
- synovial cell debris and fibrin  As the ability of the hyaluronate to
polymerize decreases, the clot becomes
 Presence of Crystals less firm, and the surrounding fluid
- fluid may appear milky increases in turbidity.
 Noninflammatory: The mucin clot test is reported in terms
- Clear, yellow fluid of:
 Inflammatory Immunologic origin: -  good (solid clot)
Cloudy, yellow fluid  fair (soft clot)
 low (friable clot)
 Crystal-induced origin:
 poor (no clot)
- Cloudy or milky fluid
The mucin clot test is not routinely performed,
 Septic:
- Cloudy, yellow-green fluid because all forms of arthritis decrease
viscosity and little diagnostic information is
 Hemmorhagic: obtained.
- Cloudy, red fluid
VISCOSITY Formation of a mucin clot after adding acetic
- Synovial fluid viscosity comes from acid can be used to identify a questionable
polymerization of the hyaluronic acid and is fluid as synovial fluid.
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SYNOVIAL FLUID
CELL COUNTS
Total leukocytes count
- most frequently performed cell count on
synovial fluid.
RBC count
- seldom requested
Cell counts
- should be perform as soon as possible.
Very viscous fluid
- may need to be pretreated by adding one
drop of 0.05% hyaluronidase in phosphate
buffer per milliliter of fluid and incubating at
37°C for 5 minutes.
Manual counts
-Mixed specimens using the Neubauer
counting chamber. Clear fluids can usually
be counted undiluted, but dilutions are
necessary when fluids are turbid or bloody.
Dilutions
- traditional WBC diluting fluid cannot be
used because it contains acetic acid that
causes the formation of mucin clots.
 If necessary to lyse the RBCs,
hypotonic saline (0.3%) or saline that
contains saponin is a suitable diluent.
 Methylene blue added to the normal
saline stains the WBC nuclei, permitting
separation of the RBCs and WBCs
during counts performed on mixed
specimens.
Recommended technique
 line a petri dish with moist paper and
place hemocytometer on two small
sticks to elevate it above the moist
paper.
 Fill and count both sides of the
hemocytometer for compatibility.
Acceptable ranges are determined by
the laboratory.
Counting
 For counts less than 200 WBCs/L,
count all 9 large squares.
 For counts greater than 200 WBCs /L in
the above count,
 count the 4 corner squares.
 For counts greater than 200 WBCs /L in
the above count,
 Count the 5 small squares used for a
RBC count.
( Automated cell counters- can be used)
-Incubating the fluid with hyaluronidase
decreases specimen viscosity-
Analyzing scatter grams
- Can aid in detecting tissue cells and debris.
Properly controlled automated counts
provide higher precision than manual counts.
WBC Counts
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SYNOVIAL FLUID
<200 cells/L - Normal and may reach
100,000 cells/L or higher in severe
infections.
Considerable overlap of elevated
leukocyte counts between septic and
inflammatory forms of arthritis.
DIFFERENTIAL COUNTS
 Should performed cytocentrifuged
preparations or on thinly smeared slides.
Fluid- should incubated with hyaluronidase
prior to slide preparation.
Primary cells seen in Synovial Fluid
 Mononuclear cells, including monocytes,
macrophages, and synovial tissue cells.
 Neutrophils should account for < 25% of
the differential count and lymphocytes <
15%.
 Increased neutrophils indicate a septic
condition, whereas an elevated cell
count with a predominance of
lymphocytes suggests a nonseptic
inflammation.
Lipid droplets
- present after crush injuries.
Hemosiderin granules
- pigmented villonodular synovitis.
CRYSTAL IDENTIFICATION
- Microscopic examination of synovial
fluid for the presence of crystals is
an important diagnostic test in
evaluating arthritis
Causes of crystal formation
 metabolic disorders
 decreased renal excretion that produce
elevated blood levels of crystallizing
chemicals
 degeneration of cartilage and bone
 injection of medications
(corticosteroids)
Types of Crystals
1. Monosodium urate (uric acid) (MSU)
- found in cases of gout
- routinely seen as needle-shaped crystals
Caused by:
 impaired metabolism of purines
 increased consumption of
high-purine-content foods, alcohol, and
fructose
 chemotherapy treatment of leukemias
 decreased renal excretion of uric acid
are the most frequent causes of gout.
Location:
- may be extracellular or located within the
cytoplasm of neutrophils.
- they are frequently seen sticking through
the cytoplasm of the cell
2. Calcium pyrophosphate dihydrate
(CPPD)
- rhomboid-shaped or square but may
appear as short rods.
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SYNOVIAL FLUID
- seen with pseudogout
- Pseudogout is most often associated with
degenerative arthritis, producing cartilage
calcification and endocrine disorders that
produce elevated serum calcium levels.
3. Cholesterol crystals
- associated with chronic
inflammation
4. Corticosteroids
- after injections
5. Calcium oxalate crystals
- in renal dialysis patients
6. hydroxyapatite (basic calcium
phosphate)
- associated with calcified cartilage
degeneration
Artifacts
 talcum powder
 starch from gloves
 precipitated anticoagulants
 Dust
 scratches on slides and cover slips.
NOTE:
Slides and cover slips should be examined
and if necessary cleaned again before use.
Slide Preparation
- Ideally, 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. Fluid is examined as an unstained
wet preparation.
2. One drop of fluid is placed on a pre
cleaned glass slide and cover
slipped.
3. The slide can be initially examined
under low and high power using a
regular light microscope
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SYNOVIAL FLUID
4. Crystals may be observed in
Wright’s-stained smears; however,
this should not replace the wet prep
examination and the use of polarized
and red-compensated polarized light
for identification.
Crystal Polarization
 Positive identification is made using
first-order red-compensated
polarized light
 Use betamethasone acetate
corticosteroid as control slide to
polarize the properties of MSU –
highly birefringent
 If the crystal run parallel to the long
axis aligned with slow vibration
produces a yellow color – negative
birefringence
If the crystal run perpendicular to the long
axis aligned with slow vibration produces a
blue color – positive birefringence
CHEMISTRY TESTS
 Glucose determination – frequently
requested
 Normal synovial fluid glucose values
are based on the blood glucose level
 Samples are obtained after 8 hours
of fasting
 Normal synovial fluid glucose – 10
mg/dL
 Other tests: Total protein, uric acid
determination
MICROBIOLOGIC TEST
Infection
- may occur as a secondary complication of
inflammation
Caused by:
 trauma or through dissemination of a
systemic infection
Gram Stains and Cultures
- two of the most important tests
performed on synovial fluid
- must be performed on all specimens
Bacterial Infections
- most frequently seen
- fungal, tubercular, and viral infections
also can occur.
- if suspected, use special culturing
procedures
Routine Bacterial Cultures
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SYNOVIAL FLUID
- use enrichment medium- chocolate agar
because in addition to Staphylococcus
and Streptococcus
- Haemophilus species and Neisseria
gonorrhoeae
(common fastidious organisms that
infect synovial fluid)

SEROLOGIC TEST

- diagnosis of joint disorders

- most of these tests are performed on serum
and synovial fluid analysis
-serves as confirmatory measure in cases
that are difficult to diagnose

Autoimmune Diseases Rheumatoid

Arthritis and Systemic Lupus
Erythematosus
- very serious joint inflammation
- diagnosed in the serology laboratory by
demonstrating the presence of their
particular autoantibodies in the
patient’s serum.
-same antibodies can also be
demonstrated in synovial fluid, if
necessary.

Arthritis
- frequent complication of Lyme disease

Thus,
Demonstrating antibodies to the causative
agent Borrelia burgdorferi in the patient’s
serum can confirm the cause of the arthritis.

REFERENCES:
Strasinger, S.K, Di Lorenzo, M.S (2014).
Urinalysis and Body Fluids (6th ed.)
Philadelphia: F.A Daviss Company