SYNOVIAL FLUID

ARAZA, ORSAJES, TOMINES

NOVEMBER 2023
 Physiology
• Synovial fluid, often referred to as “joint fluid,” is a viscous
liquid found in the cavities of the movable joints (diarthroses) or synovial joints

•The synovial membrane contains specialized cells called “synoviocytes”.

•Two types of synoviocytes are present in the synovial membrane:

- Type A cells are macrophage-like cells located in the superficial layer of the
synovial membrane and play an important role in phagocytosis.
- Type B cells are fibroblast-like cells with prominent endoplasmic reticulum
located in a deeper layer of the synovial membrane and produce hyaluronic acid,
fibronectin, and collagen to produce synovial fluid

•The synoviocytes secrete a mucopolysaccharide containing hyaluronic acid and

a small amount of protein (approximately one fourth of the plasma concentration)
into the fluid.

•Damage to the articular membranes produces pain and stiffness in the joints,
collectively referred to as “arthritis”.

•The beneficial tests performed most frequently on synovial fluid are the white
blood cell (WBC) count, differential, Gram stain, culture, and crystal
examination
 Specimen Collection and Handling

• Synovial fluid is collected from a joint by needle aspiration

called arthrocentesis

• Normal synovial fluid does not clot; however, fluid from a diseased joint may contain fibrinogen and will clot.
Therefore, fluid is collected in a syringe that has been moistened with heparin. When sufficient fluid is collected,
it should be distributed into specific tubes based on the required tests

• The Clinical Laboratory Standards Institute recommends that synovial fluid should be collected as follows:
- Tube 1: The first 4 to 5 mL of the synovial fluid obtained should be placed into a plain, nonanticoagulated red
stopper tube and observed for clotting. The tube is centrifuged to remove cellular and other components. The
supernatant is used for chemical or immunologic analysis.
• Tube 2: The next 4 to 5 mL is collected into a tube to which 25 units (U) of sodium heparin per mL (green
stopper) is added or to a ethylenediaminetetraacetic
id (EDTA) tube (lavender stopper) for cell count,
differential count, and crystal identification.
• Tube 3: The last 4 to 5 mL is placed into a sterile tube to
which 25 U per mL heparin is added (green stopper) or
to a sodium polyanethol sulfonate (yellow stopper) tube
for microbiological studies.
 Color and Clarity
Normal synovial fluid appears colorless to
pale yellow. The word “synovial” comes from
the Latin word for egg, ovum. Normal viscous
synovial fluid resembles egg white. The color
becomes a deeper yellow in the presence
of noninflammatory and inflammatory
effusions and may have a greenish tinge with
bacterial infection
• Clarity is determined by the presence of
WBCs, red blood cells (RBCs), synoviocytes,
crystals, fat droplets, fibrin, and cellular
debris in the synovial fluid.
• Turbidity is associated frequently with the
presence of WBC. The fluid may appear
milky when crystals are present.
Viscosity
Hyaluronate polymerization can be
measured using a Ropes, or mucin clot,
test. When added to a solution of 2% to
5% acetic acid, normal synovial fluid forms
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), low (friable
clot), and poor (no clot).
CELL COUNTS
The total leukocyte count is the most frequently performed
cell count on synovial fluid.
To prevent cellular disintegration, counts should be performed
as soon as possible or the specimen should be refrigerated.
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 on thoroughly mixed specimens are done using
the Neubauer counting chamber.
Acceptable ranges are determined by the laboratory.
Counting procedure:
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.2
NOTE: Do not use fluids that contain acetic acid to dilute synovial
fluid
DIFFERENTIAL COUNT
Differential counts should be performed on cytocentrifuged
preparations or on thinly smeared slides.
Fluid should be incubated with hyaluronidase prior to slide
preparation.
Neutrophils should account for less than 25% of the differential
count and lymphocytes less than 15%.
DIFFERENTIAL COUNT
Crystal Identification
Microscopic examination of synovial fluid for the presence of
crystals is an important diagnostic test in evaluating arthritis.
Crystal formation in a joint frequently results in an acute,
painful inflammation.
Additional crystals that may be present include hydroxyapatite
(basic calcium phosphate) associated with calcified cartilage
degeneration, cholesterol crystals associated with chronic
inflammation, corticosteroids after injections, and calcium
oxalate crystals in renal dialysis patients.

TYPES OF CRYSTALS
Monosodium urate (uric acid) (MSU) - found in gout
Calcium pyrophosphate dihydrate (CPPD) - seen with pseudogout
 Most frequent
causes of gout:
1. Increased serum uric
acid resulting from
impaired metabolism
of purine.
2. Increased
consumption of high-
purine-content foods,
alcohol, and fructose.
3. Chemotherapy
treatment of
leukemias.
4. Decreased renal
excretion of uric acid.
Slide Preparation
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.
The slide can be initially examined under low and high power
using a regular light microscope (Fig. 11–2).
Crystals may be observed in Wright’s-stained smears (Fig. 11–3).
Crystal Polarization
A control slide for the polarization properties of MSU can be prepared
using betamethasone acetate corticosteroid.
Both MSU and CPPD crystals have the ability to polarize light however,
MSU is more highly birefringent and appears brighter against the dark
background (Figs. 11–4 and 11–5).
When compensated polarized light is used, a red compensator is placed
in the microscope between the crystal and the analyzer (Fig. 11–6).
The color produced by each crystal when it is aligned with the slow
vibration can be used to identify the crystal.
 Normal glucose values in synovial fluid
are based on the blood glucose level,
simultaneous blood and synovial fluid
specimens should be obtained,
preferably after the patient has fasted for
8 hours.

Patients with non-inflammatory and

hemorrhagic joint disorders have synovial
Glucose fluid glucose levels of 10 and 20 mg/dL or
less than plasma levels measured
simultaneously

INFLAMMATORY DISORDERS
0 to 40 mg/dL below plasma level

INFECTIOUS AND CRYSTAL-INDUCED

20 to 100 mg/dL and 0 to80 mg/dL less than
the plasma level.
TOTAL PROTEIN

The total protein level commonly exceeds

3.0 g/dL in all but non-inflammatory
synovial effusions; therefore, it has little
diagnostic significance.
Increased levels are found in patients with
inflammatory and hemorrhagic disorders;
however, synovial fluid protein
measurement does not contribute greatly
to the classification of these disorders

NORMAL SYNOVIAL FLUID

contains less than 3 g/dL protein
(approximately one third of the
serum value).
 URIC ACID LACTATE
The elevation of serum uric acid in Synovial fluid lactate levels are
cases of gout is well known; increased in septic arthritis caused by
therefore, demonstration of an gram-positive cocci and gram-
elevated uric acid level in the negative bacilli
synovial fluid may be used to Levels greater than 9 mmol/L (81
confirm the diagnosis when the mg/dL) indicate bacterial arthritis and
presence of crystals cannot be indicate an immediate onset of
demonstrated in the fluid treatment.

ENZYMES
Acid and alkaline phosphatase,
gamma-glutamyltransferase,
adenosine deaminase,
muramidase, cytidine deaminase,
lactate dehydrogenase, and
aspartate aminotransferase, may
be tested in synovial fluid to
monitor the severity and prognosis
of RA.
 MICROBIOLOGIC
TESTS
An infection may occur as a secondary
complication of inflammation caused by
trauma or through dissemination of a
systemic infection; therefore, Gram
stains and cultures are two of the most
important tests performed on synovial
fluid. Both tests must be performed on
all specimens, as organisms often are
missed on Gram stain.
The common organisms that infect
synovial fluid are the fastidious
Haemophilus species and N.
gonorrhoeae.
SEROLOGICAL
TESTS
The autoimmune diseases RA and
systemic lupus erythematosus cause
very serious joint inflammation 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 and it’s causative agent is
B. burgdorferi.