CHAPTER 12

Definition
Synovial Fluid is often referred to as
“joint fluid”, is a viscous liquid found in
the cavities of the movable joints or
synovial joints.
 Function
➢ The synovial fluid reduces friction
between the bones during joint movement.
➢It provides lubrication in the joints.
➢ It also provides nutrients to the articular
cartilage.
➢ It lessens the shock of joint compression
occurring during activities such as walking
and jogging.
 Physiology
➢ It is formed as an
ultrafiltrate of plasma
across the synovial
membrane.
➢ Majority of the
chemical constituents
have concentrations
similar to plasma
values.
➢ Cells lining the synovial membrane
(synoviocytes) secrete a
mucopolysaccharide containing hyaluronic
acid and a small amount of protein into the
fluid.
➢ Damage to the articular membranes
produces pain and stiffness in the joints,
collectively referred to as arthritis.
➢ A variety of conditions including infection,
inflammation, metabolic disorders, trauma,
physical stress, and advanced age are
associated with arthritis.
 Normal Synovial Fluid Values
Volume <3.5 mL
Color Pale yellow
Clarity Clear
Viscosity Able to form a string 4-6 cm long
Erythrocyte count <2000 cells/µL
Leukocyte count <200 cells/µL
Neutrophils <20% of the differential
Lymphocytes <15% of the differential
Monocytes and 65% of the differential
Macrophages
Crystals None present
Glucose <10mg/dL lower than the blood
glucose
Lactate <250 mg/dL
Total protein <3 g/dL
Uric acid Equal to blood value
Specimen Collection and Handling
➢ Synovial fluid is collected by needle aspiration
called arthrocenthesis.
➢ Amount of fluid present will vary with the size of
the joint and the degree of fluid buildup in the
joint.
➢ The volume of fluid collected should be
recorded.
➢ Normal synovial fluid does not clot; however,
fluid from a diseased joint may contain
fibrinogen and may clot.
➢ To avoid clotting, the fluid is usually collected in a
syringe that has been moistened with heparin.
➢ Specimen should be distributed into 3 tubes.
* sterile heparinized tube for the microbiology section
* a liquid EDTA tube for hematology section
* nonaticogulated tube for other tests

Powdered anticoagulants should not be used

because it may produce artifacts that will interfere
with crystal analysis.
 Classification and Pathologic
Significance of Joint Disorders
Group Classification Pathologic Significance
I. Non-inflammatory Degenerative joint disorders

II. Inflammatory Immunologic problems, including

rheumatoid arthritis and lupus
erythematosus
Crystal-induced gout and pseudogout
III. Septic Microbial infection

IV. Hemorrhagic Traumatic injury

Coagulation deficiencies
 Laboratory Findings in Joint
Disorders
I. Non-inflammatory

➢ Clear, yellow fluid

➢ Good viscosity
➢ WBCs <2000 µL
➢ Neutrophils <30%
➢ Normal glucose (similar to blood glucose)
II. Inflammatory

Immunologic origin Crystal-induced origin

Poor viscosity Cloudy or Milky fluid

WBCs 2000 – 5000 µL Poor viscosity
Neutrophils >50% WBCs up to 50 000 µL
Decreased glucose level Neutrophils >90%
Possible autoantibodies Decreased glucose level
present Elevated uric acid level
Crystals present
Cloudy, yellow-green fluid
III. Septic
➢ Poor viscosity
➢ WBCs 10 000 – 200 000 µL
➢ Neutrophils >90%
➢ Decreased glucose level
➢ Positive culture and Gram
stain
IV. Hemorrhagic
➢ Cloudy, red fluid
➢ Poor viscosity
➢ WBCs <5000 µL
➢ Neutrophils <50%
➢ Normal glucose level
➢ RBCs present
 Appearance
➢ Normal synovial fluid appears clear and pale
yellow.
➢ The color becomes deeper yellow in the
presence of inflammation and may have a
greenish tinge with bacterial infection.
➢ Presence of blood from a hemorrhagic arthritis
may be distinguished from blood from traumatic
aspiration by observing the uneven distribution
of blood in a traumatic aspiration.
➢ Turbidity is frequently associated with the
presence of WBCs (synovial cell debris and
fibrin also produce turbidity). The fluid may
appear milky when crystals are present.
 Viscosity
➢ Viscosity comes from the
polymerization of hyaluronic
acid and is essential for the
proper lubrication of the
joints.
➢ Arthritis affects both the
production and ability to
polymerize of hyaluronate
thus decreasing viscosity of
the fluid.
➢ Simplest way to measure viscosity is to observe the ability
of the fluid to form a string from the tip of the syringe. 4 to 6
cm is considered normal.
➢ Measurement of the degree of hyaluronate polymerization
can be performed using Ropes, or mucin clot test.
➢ In 2 – 5% acetic, normal synovial fluid will form a solid clot
surrounded by clear fluid. As the ability of the hyaluronate
to polymerize decreases, the clot becomes less firm and
the surrounding fluid increases in turbidity.
➢ The mucin clot test is reported in terms of:
good – solid clot
fair – soft clot
poor – friable clot
very poor – no clot
 Cell Counts
➢ The total leukocyte count is the most frequently
performed cell count on synovial fluid.
➢ Red blood cell counts may be requested unless
evidence of a traumatic tap exists.
➢ Very viscous fluid should be pretreated by
adding a pinch of hyaluronidase to 0.5 mL of
fluid or one drop of 0.05 percent hyaluronidase
in phosphate buffer per mL of fluid and
incubating at 37°C for 5 minutes.
➢ Manual counts are done using the Neubauer
counting chamber in the same manner as CSF
counts.
➢ WBC diluting cannot be used because it
contains acetic acid, which will cause the
formation of mucin clots.
➢ Normal saline can be used as diluent.
➢ Methylene blue added to normal saline will stain
the WBC nuclei, permitting separation of the
RBCs and WBCs during counts.
➢ WBC counts less than 200 cells/µL are
considered normal and may reach 100 000
cells/µL or higher in severe infections.
 Differential Count
Neutrophil Lymphocyte

Description: Description:
Polymorphonuclear Mononuclear leukocyte
leukocyte Significance:
Significance: Nonseptic inflammation
Bacterial Sepsis
Crystal induced
inflammation
Synovial lining cell

Description:
Similar to macrophage,
but may be
multinucleated, LE cell
resembling a
mesothelial cell
Significance: Description:
Normal Neutrophil containing
characteristic ingested:
“round body”
Significance:
Lupus erythematosus
Reiter cell RA cell (ragocyte)

Description: Description:
Vacuolated macrophage Neutrophil with dark
with ingested neutrophils cytoplasmic granules
Significance: containing immune
complexes
Reiter’s syndrome
Nonspecific Significance:
inflammation Immunologic
inflammation
 Rice bodies

Description:
Macroscopically resemble
Cartilage cells polished rice
Microscopically show
collagen and fibrin
Description:
Significance:
Large, multinucleated
cells Tuberculosis, septic and
rheumatoid arthritis
Significance:
Osteoarthritis
Fat droplets

Description:
Refractile intracellular
and extracellular globules
Stain with Sudan dyes Hemosiderin
Significance:
Traumatic injury Description:
Inclusions within clusters
of synovial cells
Significance:
Pigmented villonodular
synovitis
 Synovial Fluid Crystals
Monosodium urate
➢ Needle-shape
➢ Negative bifringence, run
parallel to the long axis of the
crystal, with slow vibration and
produces a yellow color in
Compensated Polarized Light
➢ Found in Intracellular and
Extracellular
➢ Found in cases of gout
Calcium pyrophosphate
➢ Rod, Needles and Rhombic
shape
➢ Positive Bifringence, Run
perpendicular to the long
axis, fast vibration and
produces a blue color in
Compensated Polarized
Light
➢ Found in Intracellular and
Extracellular
➢ Found in cases of
pseudogout
Cholesterol
➢ Notched rhombic
plates shape
➢ Negative bifringence
in Compensated
Polarized light
➢ Found in
Extracellular
Corticosteroid

➢ Flat, variable-shaped plates in shape

➢ Positive and negative birefringence in
Compensated Polarized Light
➢ Found primarily in Intracellular
 Chemistry Tests
Because synovial fluid is chemically an
ultrafiltrate of plasma, chemistry test values are
approximately the same as serum values.

Glucose Test
➢ Glucose is the most requested test because markedly
decreased values are indicative of inflammatory (group
II) or septic (group III) disorders.
➢ Normal synovial fluid glucose should not be more than
10mg/dL.
➢ Glycolysis upon long standing of the specimen causes
falsely decreased values.
Lactate test

➢ Synovial fluid lactate provides rapid

differentiation between inflammatory and septic
arthritis.
➢ Synovial fluid levels greater than 250 mg/dL are
found consistently with septic arthritis, but may
also be seen in rheumatoid arthritis.
Other chemistry test

➢ Total protein and Uric acid test may be

requested because the large protein molecules
are not filtered through the synovial membranes,
normal synovial fluid contains less than 3 g/dL of
protein.
➢ Increased levels are found in inflammatory and
hemorrhagic disorders.
 Microbiology Tests
➢ Gram stains and cultures are two of the most
important tests performed on the synovial fluid.
➢ Bacterial infections are frequently seen;
however, fungal, tubercular, and viral infections
can also occur.
➢ The most frequently seen bacterial species are
Staphylococcus and Streptococcus, but other
fastidious organisms such as Hemophilus and
Neisseria gonorrhea may also be found.
 Serologic Tests
➢ The autoimmune diseases rheumatoid arthritis
and lupus eryhtematosus cause very serious
inflammation of the joints and are diagnosed in
the serology laboratory by demonstrating the
presence of their particular autoantibodies in the
patient’s serum.
➢ Arthritis is a frequent complication of Lyme
disease.
➢ Demonstration of antibodies to the causative
agent Borrelia burgdorfri in the patient’s serum
can confirm the cause of the arthritis.
END of REPORT . . .