3E Medical Technology

Name: DELOS SANTOS, Ana Loraine C.

PONCE, Patricia Nicole S.
SAY, Tiffany Ella RosedC.
TE, Tiffany Jill L.

February 7, 2014

SYNOVIAL FLUID
PHYSIOLOGY
joint fluid
Viscous liquid found in the cavities of the
movable joints (diarthroses) or synovial joints
*Bones in the synovial joints are lined with
smooth articular cartilage and separated by a
cavity containing the synovial fluid. The joint is
enclosed in a fibrous joint capsule lined by the
synovial membrane. See figure 1 for the diagram
of synovial joint.
Joint membrane contains synoviocytes
(specialized cells) = secrete a
mucopolysaccharide containing hyaluronic acid
and small amount of protein (approximately of
plasma concentration)
*hyaluronidase molecules contribute to the
viscosity of the synovial fluid
Smooth articular cartilage and synovial fluid
reduce friction between the bones during joint
movement
Provides lubrication in the joints
Provides nutrients to the articular cartilage
(vascular-deficient)
Lessens the shock of joint compression during
walking and jogging
Ultrafiltrate of plasma across the synovial
membrane
Have concentrations similar to plasma
Damage to the articular membranes = arthritis
(pain and stiffness in the joints)
*associated with infection, inflammation,
metabolic disorders, trauma, physical stress,
advanced age
Laboratory results determine pathologic origin of
arthritis
Tests: WBC count, differential, Gram stain,
culture, crystal examination
SPECIMEN COLLECTION AND HANDLING
Collected by arthrocentesis (needle aspiration
syringe that has been moistened with heparin)
Amount collected varies with the size of the joint
and the extent of fluid buildup in the joint
Normal synovial fluid does not clot
*fluid from diseased joint may contain
fibrinogen and will clot

Figure1. Diagram of Synovial joint.

Fluid distribution based on required tests:

Gram stain and culture sterile
heparinized tube
Cell counts Heparin or
ethylenediaminetetraacetic acid (EDTA)
tube
Other tests nonanticoagulated tube
(centrifugated, separated to prevents
cellular elements from interfering with
chemical and serological analyses)
Glucose analysis Sodium fluoride
tube
Powdered anticoagulants should not be used
because they may produce artifacts that interfere
with crystal analysis
All tests should be done as soon as possible to
prevent cellular loss and possible changes in
crystals
NORMAL SYNOVIAL FLUID VALUES
Volume
<3.5 ml
Color
Colorless to pale
yellow
Clarity
Clear
Viscosity
Able to form a string
4-6 cm long
Leukocyte count
<200 cells/ L
Neutrophils
<25% of the
differential
Crystals
none present

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Glucose plasma
<10 mg/dL lower than
difference
the blood glucose
Total protein
<3 g/dL
Table1. Normal Synovial Fluid Values
CLASSIFICATION AND PATHOLOGIC
SIGNIFICANCE OFJOINT DISORDERS
Group Classification
Pathologic Significance
1. Noninflammatory
Degeneratibe joint
disorders, osteoarthritis
2. Inflammatory
Immunologic disorders,
rheumatoid arthritis,
lupus erythematosus,
scleroderma,
polymyositis,
anklylosing spondylitis,
rheumatic fever, and
lyme arthritis
Crystal-induced gout and
pseudogout
3. Septic
Microbial infection
4. Hemmorhagic
Traumatic injury, tumors,
haemophilia, other
coagulation disorders
Anticoagluant disorders
Table2. Classification and Pathologic Significance of
Joint Disorders
LABORATORY FINDINGS IN JOINT
DISORDERS
Group Classification
Laboratory Findings
1. Noninflammatory
Clear, yellow fluid
Good viscosity
WBCs <1000L
Neutrophils <30%
Normal glucose (similar
to blood glucose)
2. Inflammatory
Cloudy, yellow fluid
(immunologic origins) Poor viscosity
WBCs 2000-75,000 L
Neutrophils >50%
Decreased glucose level
Possible autoantibodies
present
(crystal-induced)
Cloudy or milky fluid
Low viscosity
WBCs up to 100,000 L
Neutrophils <70%
Decreased glucose level
Crystals present
3. Septic
Cloudy, yellow-green

fluid
Variable viscosity
WBCs 50,000-100,000
l
Neutrophils >75%
Deceased glucose level
Positive culture and
Gram stain
4. Hemorrhagic
Cloudy, red fluid
Low viscosity
WBCs equal to blood
Neutrophils equal to
blood
Normal glucose level
Table3. Laboratory Findings in Joint Disorders
COLOR AND CLARITY
Report of gross appearance is essential
Colorless to pale yellow
*deep yellow - presence of noninflammatory and
inflammatoryeffusions
*greenish tinge bacterial infection
Resembles egg white
*synovial Latin for egg
Presence of blood in synovial fluid
*distinguish from hemorrhagic disease or
traumatic aspiration (uneven distribution of
blood)
Turbidity presence of WBCs or synovial cell
debris and fibrin
Milky presence of crystals
VISCOSITY OF THE SYNOVIAL FLUID
Depends on the polymerization of hyaluronic
acid
Proper lubrication of the joints
Arthritis
Affects the musculoskeletal system, specially the
joints
Affects both the production of hyaluronate and
its ability to polymerize
Methods in measuring the viscosity
1. String test
- Test based on the ability of the fluid to form
a string from the tip of the syringe.
- Normal: 4-6 cm
2. Ropes test or mucin clot test
- Measures the amount of hyaluronate
polymerization by adding 2% to 5% acetic
acid in a normal synovial fluid forming a
solid clot surrounded by clear fluid.

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As the ability of the hyaluronate to

polymerize decreases, the clot become less
firm, and the surrounding fluid increases in
turbidity.
- Manner of Reporting: Good (solid clot), Fair
(soft clot), Low (friable cot), Poor (no clot)
CELL COUNTS
Total leukocyte count (most frequently
performed cell count)
Must be performed ASAP or specimen must be
refrigerated
For a very viscous fluid, add a pinch of
hyaluronidase to 0.5 mL of fluid or one drop of
0.05% hyaluronidase in phosphate buffer per
milliliter of fluid and incubate at 37C for 5
minutes.
For manual counting, Neubauer counting
chamber is used.
Clear fluids are counted undiluted while in the
bloody fluid or fluids are turbid, dilution is
necessary.
Normal saline is used as diluent
WBC diluting fluid cannot be used because it
contains acetic acid associated in formation of
mucin clots.
To lyse RBCs, hypotonic saline (0.3%) or saline
with saponin is a good diluent
Methylene blue added in normal saline stains
WBC nuclei.
Automated cell counter can be used but in cases
of a very viscous fluids, it may block the
apertures and falsely elevate counts may be

Not routinely performed because all arthritis

decrease viscosity and little diagnostic
information
- Formation of a mucin clot following the
addition of acetic acid can be used to
identify a questionable fluids
obtained due to the presence of debris and tissue
cells
Scattergram analysis can aid in detecting of
tissue cells and debris.
Normal WBC count: less than 200 cell/L

DIFFERENTIAL COUNT
Performed on cytocentrifuged preparations or on
thinly smeared slide
Incubation with hyaluronidase is needed prior to
slide preparation.
Mononuclear cells are primary cells in normal
synovial fluids
Neutrophils: less than 25%. If increased, it
indicates septic condition.
Lymphocytes: less than 15%. If increased, it
indicates nonseptic inflammation.
Presence of eosinophils, LE cells, Reiter cells
(vacuolated macrophages with ingested
neutrophils) and RA cells or ragocytes
(neutrophils with small, dark, cytoplasmic
granules that consist of precipitated rheumatoid
factor) also an indication of abnormalities.
Lipid droplets- crush injuries
Hemosiderin granules- pigmented villonodular
synovitis

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CELLS AND INCLUSIONS SEEN IN SYNOVIAL FLUIDS

Description
Significance
Polymorphonuclear leukocyte
Bacterial sepsis
Crystal-induced inflammation
Lymphocyte
Mononuclear leukocyte
Nonseptic inflammation
Macrophage (monocyte)
Large mononuclear leukocyte, may be
Normal
vacuolated
Viral infections
Synovial lining cell
Similar to macrophage, but may be
Normal
multinucleated, resembling a
mesothelial cell
LE cell
Neutrophil containing characteristic
Lupus erythematosus
ingested: round body
Reiter cell
Vacuolated macrophage with ingested
Reiter syndrome
neutrophils
Nonspecific inflammation
RA cell (ragocyte)
Neutrophil with dark cytoplasmic
Rheumatoid arthritis
granules containing immune complexes Immunologic inflammation
Cartilage cells
Large, multinucleated cells
Osteoarthritis
Rice bodies
Macroscopically resemble polished rice Tuberculosis, septic and
Microscopically show collagen and
rheumatoid arthritis
fibrin
Fat droplets
Refratile intracellular and extracellular
Traumatic injury
globules
Chronic inflammation
Stain with Sudan dyes
Hemosiderin
Inclusions within clusters of synovial
Pigmented villonodularsynovitis
cells
Table 4. Cells and Inclusions seen in Synovial Fluid
o Pseudogout associated with degenerative
arthritis, producing cartilage calcification
CRYSTAL IDENTIFICATION
and endocrine disorders that produce
Acute, painful inflammation and chronic
elevated serum calcium levels
condition crystal formation in the joints
Additional Crystals
Causes of Crystal Formation
o Hydroxyapatite(basic calcium phosphate)
o Metabolic disorders
associated with calcified cartilage
degeneration
o Decreased renal excretion
o Cholesterol crystals associated with
o Degeneration of cartilage and bones
chronic inflammation
o Injection of medications such as
o
Corticosteriods following injections
corticosteroids
o Calcium oxalate crystals in renal dialysis
patients
Types of Crystals
Artifacts
Monosodium urate(MSU) and Calcium
o Talc
pyrophosphate(CPPD) primary crystals found
in synovial fluid
o Starches from gloves
o Monosodium urate seen in gout
o Precipitated anticoagulants
o Calcium pyrophosphate seen in
o Dusts
pseudogout
o Scratches on slides and coverslips
o Most frequent causes of Gout
Increased serum uric acid resulting from
Slide Preparation
impaired metabolism of purines
Crystal examination should be performed soon
Increased consumption of high purine
after fluid collection because crystals can be
content food, alcohol and fructose
affected by changes in temperature and pH
Chemotherapy treatment
MSU and CPPD crystals are reported
Decreased renal excretion of uric acid
intracellulary and extracellularly
Cell/ Inclusion
Neutrophil

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Unstained Wet Preparation

o 1 drop of fluid placed on a precleaned slide
and coverslipped
o Examined initially under low and high
power in a regular light microscope
o Wright stained smears for crystal
observation
o Polarized and compensated polarized light for Crystal Idetification
MSU crystals needle shaped crystals which
maybe seen extracellularly or sticking through
the cytoplasm of the neutrophils; they lyse
phagosome membranes
CPPD Crystals rhombic shaped or square but
may appear as short rods located within the
vacuoles of the neutrophils

Figure2. CPPD Crystals on Wright stain Preparation

Crystal Polarization
Compensated polarized light for positive
identification
o Red compensator is used and placed in
the microscope between the crystal and
analyzer to separate the light ray into slow
moving and fast moving vibrations and
produces red background
Betamethasone acetate corticosteroid can be
used as a control slide for the polarization of
MSU

MSU crystals
run parallel to the long axis of the
crystal
when aligned with the slow vibration,
the velocity of the slow light passing
through the crystal is not impeded as
much as the fast light which runs
against the grain and produces yellow
color
negative birefringence(subtraction of
velocity from the fast ray)
CPPD crystals
run perpendicular to the long axis of the
crystal
when aligned with the slow axis, the
velocity of the fast light passing through
the crystal is much quicker producing
blue color
positive birefringence

Figure3. MSU and CPPD Crystals showing negative

and positive birefringence respectively
o Cholesterol, oxalate, corticosteroid, apatite
crystals and contaminants
Shows crystal shapes and varying
patterns of birefringence from the
standard MSU and CPPD patterns
Further investigation is required
Cholesterol, oxalate, corticosteroid
crystals and contaminants
Exhibit birefringence
Apatite crystals
Do not exhibit birefringence

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CHARACTERISTICS OF
SYNOVIAL FLUID CRYSTALS
Crystal
Shape
Compensated Polarized Light
Monosodium urate
Needles
Negative birefringence
Calcium pyrophosphate
Rhombic square, rods
Postive birefringence
Cholesterol
Notched, Rhombic plates
Negative birefringence
Corticosteriods
Flat, variable shaped plates
Postive and Negative birefringence
Calciumoxalate
Envelopes
Negative birefringence
Apatite (Ca phosphate)
Small particles require
No birefringence
electron microscopy
Table 5. Characteristics of Synovial Fluid Crystals
CHEMISTRY TESTS
Glucose determination
o most frequently requested
o decreased: inflammatory or septic disorders
o blood & glucose obtained after 8-hour
fasting
o Normal range of synovial fluid glucose
should not be 10 mg/dL lower than the
blood value
o specimens should be analysed within 1 hour,
or preserved with sodium fluoride
Total Protein determination
o normal synovial fluid contain 3 g/dL protein
o Increased: inflammatory & hemorrhagic
disorders
o does not contribute greatly to classification
of the disorders
Uric Acid determination
o increased: gout
MICROBIOLOGIC TESTS
Gram stain & culture
o most important tests performed on synovial
fluid
o Bacterial infections most frequently seen;
however, fungal, tubercular and viral
infections can occur
o Enrichment medium: chocolate agar
o Common organisms found: Staphylococcus,
Streptococcus, Haemophilus species and N.
gonorrhoeae

Significance
Gout
Pseudogout
Extracellular
Injections
Renal dialysis
Osteoarthritis

SEROLOGIC TESTS
actual analysis of synovial fluid as confirmatory
measure
Rheumatoid arthritis and lupus erythematosus:
autoantibodies in synovial fluid & serum
Lyme disease: causative agent Borrelia
burgdorferi found in serum
Extent of inflammation determined through
measurement of acute phase reactants such as
fibrinogen and C-reactive protein
REFERENCE
Strasinger, S.K, Di Lorenzo, M.S (2008) Synovial
Fluid. Urinalysis and Body Fluids, (5th Ed., pp. 211218). Philadelphia: FA. Davis Company
Images from
Summers, K. (2013). Why Do Joints Pop? Retrieved
February 1, 2014,
fromhttp://theyogadr.com/blog/2013/02/28/whyjoints-pop/
(n.a). 2013. Synovial Fluid CPPD. Retrieved
February 1, 2014, from
http://www.med.upenn.edu/synovium/SFCPPDgaller
y/viewer.swf
Bishop, J. USMLE Pathologic Slides. Retrieved
February 1, 2014, from
http://usmlepathslides.tumblr.com/post/20250134901
/synovial-fluid-crystals-with-red-filter-in-place

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NOTES