SYNOVIAL FLUID

Synovial fluid referred as to “joint fluid” is a viscous

liquid in the cavities of diarthroses (synovial joints
lines with smooth articulate cartilage and
separated be a cavity. It an ultrafiltrate of plasma
which lubricates the joint, provide nutrients to the
articular cartilage and lessen the shocks of joint
compression. It

The joint is enclosed in a fibrous joint capsule lined

by synovial membrane containing synoviocytes.
Synoviocytes secretes a mucopolysaccharide
substance, hyaluronic acid and small amount of
proteins.

Arthritis occurs when articular membrane is

damage causing pain and joint stiffness. Condition
as infection, inflammation, metabolic disorder,
trauma, physical stress and advanced aged may be Figure 1 Synovial joint
associated.

There are four classifications of joint disorders: noninflammatory, inflammatory, septic, and
hemorrhagic and its corresponding pathologic disorder. Arthrocentesis is the collection of synovial
fluid by needle aspiration. Tests most frequently used for synovial fluid are WBC count, differential
count, Gram stain, culture, and crystal examination. Normally, there is less than 3.5 ml in an adult
knee cavity, but it increases up to greater than 25 ml with inflammation. A normal synovial fluid does
not clot but a fluid from a disease joint may contain fibrinogen and will clot. Thus, fluid is collected
through a syringe moistened with heparin. When sufficient fluid is collected, it should be distributed
into the following tubes based on the required tests:

 A sterile heparinized tube for Gram stain and culture

 A heparin or EDTA tube for cell count
 A nonanticoagulated tube for other tests
 A sodium fluoride tube for glucose analysis

Powdered anticoagulants should not be used because it may produce artifacts. The
nonanticoagulant tube for other tests must be centrifuged and separated to prevent cellular
elements from interfering with chemical and serologic analyses. Ideally, test should be performed as
soon as possible.
Table 1. Classification of Synovial Fluid based on Laboratory Examination
Test Normal Noninflamatory Inflammatory Septic Hemorrhagic
Volume (ml) <3.5 >3.5 >3.5 >3.5 >3.5
Color Pale yellow Yellow Yellow-white Yellow- Red-brown
green
Viscosity High High Low Low Decreased
Leukocyte <200 <3000 3000 to 50,000 >50,000 <10,000
count
(cells/μL)
Neutrophils <25% <25% >50% >75% >25%
Glucose Approx. Approx. equal to < that of < that of Approx. equal
concentration equal to that of plasma plasma plasma that of
that of plasma
plasma
Glucose: P-SF* <10 mg/dL < 25 mg/dL > 25 mg/dL > 40 mg/dL < 25 mg/dL
difference
Culture Negative Negative Negative Positive Negative
Pathological Degenerative joint Immunologic Microbial Traumatic
significance disorder disorder infection injury
Osteoarthritis Rheumatoid Tumors
Osteochondritis arthritis Hemophilia
Osteochondrmatosi Crystal Joint
s synovitis prosthesis
Traumatic arthritis (Gout, Anticoagulant
Neuroarthropathy Psuedogout) overdose
Lupus
erythromatos
us
Scleroderma
Polymyositis
Ankylosing
sponylitis
Rheumatic
fever
Lyme arthritis
Reiter’s disease

Normal synovial fluid appears colorless to pale yellow. It becomes deeper yellow in the presence of
noninflammatory and inflammatory effusions, and may have tinge of green due to microbial
infection. Hemorrhagic arthritis must be distinguished from blood from a traumatic aspiration.
Uneven distribution of blood specimen is seen from a traumatic aspiration. Presence of turbidity is
associated in the presence of WBCs. Milky fluid is caused by crystals.

Viscosity comes from polymerization of the hyaluronic acid and is essential for proper join
lubrication. It is measured though the Ropes , or mucin clot test. Acetic acid (2-5%) is added in the
fluid. A normal synovial fluid I forms a solid clot surrounded by clear fluid. As polymerization
decreases, clot becomes less firm. Mucin clot test is reported in terms of good (solid clot), fair (soft
clot), low (friable clot) and poor (no clot). However, this test is not routinely performed.

Total leukocyte count is the most frequently performed test. RBC count is seldom requested. To
prevent cellular degradation, counts must be performed as soon as possible. Very viscoud fluid may
be pretreated by adding a pinch of hyalurodinase to 0.5 ml of fluid or 0.05% hyalurodinase in
phosphate buffer per milliliter and incubate at 37°C for 5 minutes. Manual counting is done using
Neubauer counting chamber. Clear fluid can be usually counted undiluted, but dilution is necessary if
turbid or bloody. Traditional WBC diluting fluid cannot be used because it contains acetic acid.
Normal saline can be used as diluents. If RBC is necessary to lyse, hypotonic saline (0.3%) or saline
containing saponin is suitable. Methylene blue is added to stain WBC nuclei. WBC counts less than
200 cells/μL are considered normal. Severe infection may reach 100,000 cells/μL or higher.

Figure 2 Comparison between (a) a healthy normal synovial membrane and it l components from (b) a rheumatic arthritis
becoming hyperplatic and the presence of inflammatory cell.

Differential count should be performed on cytocentrifuge preparations or on thinly smeared slides.

Fluid should be incubated with hyaluronidase prior to slide preparation. Mononuclear cells are the
primary cells seen in the normal synovial fluid. In both normal and abnormal specimens, cells appear
more vacuolated than they do on blood smear. Inceased number of normal cells, other than
ablnormalities includes the presence of eosinophils, LE cells, Reiter cells, and RA cells (ragocytes).
Lipid droplet may be present following crush injuries, hemosiderin granules are seen in pigmented
villonodular synovitis.
Table 2. Cells and Inclusion in Seen in the Synovial Fluid
Cell/Inclusion Description Significance
Neutrophil Polymorphonuclear Bacterial sepsis
leukocyte Crystal-induced
inflammation

Lymphocyte Mononuclear Nenseptic

leukocyte inflammation

Macrophage Large mononuclear Normal

(Monocyte) leaukocyte (may be Viral infection
vacuolated)

Synovial lining Similar to Normal

cell macrophage, but
may be
multinucleated,
resembling a
mesothelial cell

LE cell Neutrophil Lupus

containing erthromatosus
characteristics
ingested: “round
body”
 Reiter cell Vacuolated Reiter syndrome
macrophage with Nonspecific
ingested neutrophils inflammation

Ragocyte Neutrophil with dark Rheumatoid

(RA cell) cytoplasmic granules arthritis
containing immune Immunologic
complexes inflammation

Cartillage cells Large, Osteoarthritis

multinucleated cells
Rice bodies Macroscopic: Tuberculosis, Microscopic
polished rice Septic and
Microscopic: Rheumatoid
collagen & fibrin arthritis

Macroscopic

Fat droplets Refractile Traumatic injury (Sudan dye stain)

intracellular & Chronic
extracellular inflammation
globules

(Micrograph)
 Hemosiderin Inclusions with Pigmented
clusters of synovial villonodular
cells synovitits

Crystals are important diagnostic test in microscopic examination for arthritis. This may result to an
acute, painful inflammation and may become chronic. Metabolic disorder and decreased renal
excretion cause crystal formation producing elevated blood levels of crystal chemicals, degeneration
of cartilage and bone and injection of medication. Primarily, monosodium urate (uric acid) (MSU) is
found in cases of gout and calcium pyrophosphate (CPPD) in pseudogout. Increased serum uric acid
resulting from metabolim of purines, increased consumption of high purine content foods, alcohol,
and fructose, chemotheraphy treatment of leukemias, and decreased renal excretion of uric acid are
the most frequent causes of gout. Pseudogout is most often associated with degenerative arthritis,
producing cartilage calcification and endocrine disorders that produce elevated serum calcium levels.

Other crystals that may be present are as follows:

 Hydroxyl-apatite (basic calcium phosphate) associated with calcified cartilage degeneration;
 Cholesterol crystals associated with chronic inflammation;
 Corticosteroids following injections; and
 Calcium oxalate crystals in renal dialysis patients.

Table 3. Characteristics of Crystals

Compensated
Crystal Shape Polarized Significance
Light
 Monosodium Negative
Needles Gout
urate birefringence

Calcium Rhombic
Positive
pryophosphat square, Pseudogout
birefringence
e rods

Notched,
Negative
Cholesterol rhombic Extracellular
birefringence
plates

Plat,
Positive and
variable-
Corticosterois Negative Injection
shaped birefringence
plates

Calcium Negative Renal

Envelopes
oxalate birefringence dialysis

Small
particles
Apatite (Ca No
Require Osteoarthritis
phosphate) birefringence
electon
microscopy

Examination under slide preparation must be performed as soon as possible and examined unstained
wet preparation (LPO and HPO). Wright stain is used for observing crystals, but this should not
replace the wet preparation and the use of polarized and compensated polarized light for
identification.

Chemical tests are clinically important in synovial fluid, an ultrafiltrate of plasma. Glucose
concentration which is based on blood glucose level is preferably measured to a patient who fasted
for 8 hours to allow equilibration. Glucose should not be more than 10 mg/dl lower than the blood
value. To prevent falsely decreased values (glycolysis), specimen should be analyzed within 1 hour or
preserved with sodium fluoride. Other tests that may be requested are total protein and uric acid
determination.

Gram stain and culture are two of the most important test performed in synovial fluid in case of
infection. Fastidious Haemophilus species and N. gonorrhoeae are the common microbes that infect
the synovial fluid. On the other hand, serologic tests are performed to diagnose autoimmune disease
rheumatoid arthritis and lupus erythromatosus. Arthritis is also a frequent complication of Lyme
disease of Borrelia burdorferi in patient’s serum. The extent of inflammation can be determined
through measurement of the concentration of acute phase reactant (fibrinogen and CRP).