Cynovial fluid

By
Dr. Gouse Mohiddin Shaik
 CSF
• Synovial fluid is a viscous colorless
liquid that is found in the joint cavities
• Also known as joint fluid
 CSF
• Formations
• Formed as a ultrafiltrate of the plasma
across the synovial membrane
• Contains a mucopolysacharide
containing hyaluronic acid and small
amount of protein secreted by the cells
of synovial membrane
• Essentially the same chemical
composition can be found as of plasma
except large proteins
• Main difference from other fluids is
hyaluronic acid
 Synovial fluid
• Joint fluid
 CSF
• Functions
• Main function is to lubricate the joint space
• As a lubricant to the surfaces of the frequently
moving joings
• Supplies nutrition to the cartilage
• Synovial fluid has to move to supply fresh
nutrition
• Joint movement is essential for cartilage
maintenance. Movement
• Acts as shock absorber of tremendous impact
resulted due to walking running and jumping
thus acting as hydraulic fluid
 CSF
• Sample collection
• Needle aspiration of the knee called
arthocentesis
• Normally knee contains almost 3.5 ml
• Volume increases during joint problems (can
be up to 25 ml)
• Sample is divided in to 3 tubes
• For crystals and cell counts
• For microbiology
• For chemical and immunological tests
 CSF
• Purpose of Synovial fluid analysis

• To identify joint problems

• To diagnose certain types of arthritis and
inflammatory joint diseases
 Synovial fluid analysis
Physical examination Appearance
Color Normal synovial fluid is pale yellow color

Abnormal colors
Dark red or dark Deep yellow or green TRANSPARENCY
brown (bloody) may tinge may be due to Normal synovial fluid is
be due to cyrstal clear
1. Fracture 1. Bacterial infection
2. Tumor 2. Chronic rheumatoid Turbid – presence of
3. Traumatic arthritis arthritis leukocytes
4. Hemophilic arthritis
5. Presence of Milky appearance due to Cloudy – crystals
infection 1. Gouty arthritis
Traumatic tap can also 2. Tuberculous arthritis
be observed by 3. Systemic lupus
uneven distribution erythmatosis (SLE)
of blood in syrenge 4. cyrstals
.
Synovial fluid analysis
 Synovial fluid analysis
Physical examination Appearance
Volume Depending on age and depending on joint varies.

Viscosity • Normal synovial fluid is highly viscous due to

polymerization of the hyaluronic acid.
• string test : when dropped from syringe if
string of 4-6 cm is formed then viscosity is
normal
• If drop falls like water then the viscosity is low.
• Low viscosity is the result of depolymerization
of hyaluronic acid which can happen in following
conditions
•1. Rheumatoid arthritis
• 2. Septic arthritis
•3 Gout
•Dilution of haluronate complex or decreased
production can be observed in trauma
•THE MUCIN CLOT FORMATION TEST usful.
 Synovial fluid analysis
Physical examination Appearance
Viscosity STRING TEST

Nromal Low
 Synovial fluid analysis
Physical examination THE MUCIN CLOT FORMATION TEST
Clot formation Adding acetic acid to diluted synovial fluid forms
clot.
If hyaluronic acid is normal a tight ropy mass
forms in a clear solution
If softer clot formed in a turbid solution then the
mucin is considered good to fair
If the precipitate contains shreds then the mucin
is poor
 Synovial fluid analysis
Physical examination CLOT FORMATION
Clot formation Because of lack of fibrinogen and other clotting
factors synovial fluid doesn’t clot
Inflammation allow the plasma clotting factors to
escape in to joint fluid which then clot
 Synovial fluid analysis
Microscopic Cell count and differential staining
examination
• Cell count should be finished without any delay to avoid
clumping of leukocytes.
• Degeneration of Leukocytes happens if stored morethan
1 hour after sample collection
• If the sample is very thick , to facilitate cell counting
sample can be incubated at 37°C with hyaluronidase
enzyme.
• RBCs are usually very low in number. Traumatic tap
may result in high number
•Types of cells seen
•Lymphocytes •Synovial tissue cells
•Polymorpho nuclear cells •Macrophages
•Fat bodies •Bacteria
 Synovial fluid analysis
Microscopic Cell count and differential staining
examination
High neutrophil indicates septic inflammation
1. Bacterial arthritis
2. Gouty arthritis
3. Rheumatoid arthritis
High lymphocytes indicates non-septic inflammation
1. Viral infection
2. Rheumatoid arthrities
High eosinophils can be found during
1. Metastatic carcinoma
2. Acute rheumatic fever
3. Rheumatoid arthritis
 Synovial fluid analysis
Microscopic Crystals
examination
Crystals indicate the presence of crystal induced arthritis
As crystals are affected by pH, temperature test should be
performed immedetely
Endogenous crystals Exogenous crystals
1. Monosodium urate (MSU) 1. Gloves powder
needle like seen in gout 2. Corticosteroids
2. Calcium pyrophosphate
dehydrate – needles, plates or
rods like
3. Cholesterol – flat rectangular
4. Calcium oxalate – envelop
shape
5. Calcium phosphate – small
particles
Synovial fluid analysis
 Synovial fluid analysis
Chemical As Synovial fluid is ultrafiltrate of plasma chemical
examination analysis values are almost same as plasma values
Glucose
1. Normal value is 0-10% lower than that of serum level
2. When ever joint fluid glucose level is assayed, blood
glucose lever also need to be assyaed
3. During inflammatory joint diseases like rheumatoid
arthrites joing fluid glucose level may dorp to 60% of
plama or even to 40 % during septic arthritis
Protein
Protein concentration of synovial fluid remain substantially
less than in plasma. In Knee aspirates total protein is
generally and roughly 20% of the that of plasma.
Protein concentration greater than 3 g/dl may be due to
increased permeability of antibodies in the following
cases
1. Rheumatoid arthritis
2. Gout
3. Septic arthtitis
 Synovial fluid analysis
Chemical As Synovial fluid is ultrafiltrate of plasma chemical
examination analysis values are almost same as plasma values
Uric acid
Hyperurecemic patients usually accumulate crystals of
uric acid in the synovial fluid. This is seen especially
attacks of Gout.
Accumulation of uric acid crystals are due to
overproduction of uric acid or low excretion by the kidneys
When serum uric acid levels are chronically higher than
10 mg/dl then the chance of Gout attack is 90%
Alkaline phosphatase
Increased in most cases of arthritis
 Next class
Cystic fibrosis &
sweat analysis