Joint fluid interpretation

geekymedics.com/joint-fluid-interpretation

July 2, 2018

This guide provides a structured approach to joint fluid interpretation, including typical
joint fluid aspiration results for specific disease processes. Reference ranges vary between
labs, so always consult your local medical school or hospital guidelines.

Normal joint fluid results (adults)

Colour: Colourless
Clarity: Transparent
Viscosity: Normal
WBC: < 200 cells/mm3
Neutrophils (% of total WCC): <25 %
Gram stain: Negative
Crystals: Negative

Overview of joint fluid findings

This table summarises the typical findings in joint fluid analysis for various pathologies.

Joint fluid analysis

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Non-inflammatory joint effusion

Causes
Osteoarthritis (OA)
Trauma

Symptoms
Localised joint pain
Gradual onset of symptoms
Pain on movement
Crepitus
Worse at the end of the day

Typical joint fluid findings

Colour: Straw like
Clarity: Translucent
Viscosity: Increased
WBC: 200 – 2000 cells/mm3
Neutrophils: <25 %
Gram stain: Negative
Crystals: Negative

Further investigations
Bloods – WCC/CRP would typically be normal
X-Ray – may reveal fractures or changes consistent with OA
MRI – useful for assessing the ligaments and menisci for injury

Inflammatory joint effusion

Causes
Rheumatoid arthritis
Reactive arthritis
Psoriatic arthritis
Acute gout or pseudogout

Symptoms
Rheumatoid arthritis:

Symmetrical swollen, warm, erythematous and painful joints

Usually the small joints of the hands and feet are affected
Morning stiffness greater than one hour
May be associated with systemic features (fever, weight loss)
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Psoriatic arthritis:

Affected joints are generally red or warm to the touch

Small joints of the hand and wrist are commonly affected (most commonly the distal
interphalangeal joints)
Typically asymmetrical in presentation
Associated changes to the nails, such as onycholysis and hyperkeratosis

Acute gout:

Typically presents with a single hot, swollen and tender joint (most commonly the
MTP joint at the base of the big toe)

Pseudogout:

Typically presents with a single hot, swollen and tender joint (most commonly the
knee joint)

Typical joint fluid findings

Colour: Yellow
Clarity: Cloudy
Viscosity: Decreased
WBC: 2000–50,000 cells/mm3
Neutrophils: >50 %
Gram stain: Negative
Crystals: Positive
Gout – needle negative birefringent crystals
Pseudogout – rhomboid positively birefringent crystals

Further investigations
Bloods:
Full blood count
CRP/ESR
Urate (raised in gout)
Antibodies (e.g. anti–CCP, RhF)
X-ray of the joint

Septic joint effusion

Causes
Staphylococcus aureus
Streptococci
Neisseria gonorrhoeae (young sexually active adults)
Escherichia coli (elderly, IV drug users)

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Symptoms
Painful, swollen and warm
Usually a single joint affected

Typical joint fluid findings

Colour: Yellow/green
Clarity: Cloudy/opaque
Viscosity: Decreased
WBC: >50 000 cells/mm3
Neutrophils: >75 %
Gram stain: Often positive
Crystals: Negative

Further investigations
Bloods:
Full blood count – WCC raised
CRP – raised
Blood cultures
Fluid cultures
X-Ray of the joint

Haemorrhagic joint effusion

Causes
Trauma
Tumours
Bleeding disorders

Symptoms
Painful, swollen and warm
Restricted range of movement
Excessive bruising surrounding affected joint

Typical joint fluid findings

Colour: Red/xanthochromic
Clarity: Bloody
Viscosity: Variable
WBC: 200-2000 mm³
Neutrophils: 50-75%
Gram stain: Negative
Crystals: Negative

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Further investigations
Bloods:
Full blood count – may note drop in haemoglobin
Coagulation studies
X-Ray of the affected joint – to identify associated fractures

Worked examples

CASE 1
A 23-year-old female presents with a swollen and warm knee joint that is very painful on
flexion. On systemic enquiry, she also mentions she has been suffering from purulent
vaginal discharge for several weeks. She is sexually active with multiple partners and uses
condoms inconsistently. Her knee joint is aspirated, with the results shown below.

Results

Colour: Yellow
Clarity: Opaque
Viscosity: Decreased
WBC: 60,000 mm³
Neutrophils: 90 %
Gram stain: negative

Answer

Septic arthritis (likely organism Neisseria gonorrhoeae)

CASE 2
A 25-year-old male presents with pain in the metacarpophalangeal (MCP) joints of both
hands. He has morning joint stiffness that lasts for more than an hour. On examination, you
note multiple warm, swollen MTP joints, with associated erythema. The largest joint
effusion is aspirated, with the results shown below.

Results
Colour: Yellow
Clarity: Cloudy
Viscosity: Decreased
WBC: 40,000 mm³
Neutrophils: 60 %
Gram stain: Negative

Answer
Inflammatory joint effusion (secondary to rheumatoid arthritis)

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CASE 3
A 67-year-old female presents with left knee stiffness and pain that worsens with
movement. Her symptoms have progressively worsened over the last 8 years and she is
now struggling to mobilise outside. On examination, there is left knee swelling, with
significant crepitus noted on passive flexion and extension. There is no associated
erythema or warmth. There is a positive sweep test on assessment and the effusion is
aspirated, with the results shown below.

Results

Colour: Colourless
Clarity: Translucent
Viscosity: Increased
WBC: 1500 mm³
Neutrophils: 15 %
Gram stain: Negative

Answer

Non-inflammatory joint effusion (secondary to osteoarthritis)

References
1. Abdullah S, Young‐Min SA, Hudson SJ, Kelly CA, Heycock CR, Hamilton JD. Gross
synovial fluid analysis in the differential diagnosis of joint effusion. Journal of Clinical
Pathology. 2007;60(10):1144-1147. doi:10.1136/jcp.2006.043950.

2. Goldenberg DL. Bacterial arthritis. In: Ruddy S, Harris ED, Sledge CB, Kelley WN,
eds. Kelley’s Textbook of Rheumatology. 6th ed. Philadelphia, Pa.: Saunders; 2001:1469–
1483.

3. Schumacher HR Jr. Synovial fluid analysis and synovial biopsy. In: Ruddy S, Harris ED,
Sledge CB, Kelley WN, eds. Kelley’s Textbook of Rheumatology. 6th ed. Philadelphia, Pa.:
Saunders; 2001:605–619.

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