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Muhammad Asif Zeb
Lecture Hematology
IPMS-KMU
Objective
Physiology and Composition of Synovial Fluid
Specimen Collection
Laboratory Testing
Macroscopic Evaluation
...
Synovial Fluid
Synovial
syn(like) + ovia (egg)
“Joint Fluid”
Synovial Fluid
Viscous fluid found in the
cavities of movable joints
Synovial membrane
Inner membrane of
synovial joint...
Composition
Hyaluronic acid
synthesized by the synovial membrane
increase the viscosity and elasticity of articular
car...
Major Functions
Reducing friction
Lubrication
Lessen shock
Supplying oxygen and
nutrients
Synovial Fluid:
Specimen Collection
Bulge test
The Bulge test is used to determine if there is an
abnormal amount of fluid surrounding a joint
Bulge test of j...
Bulge Test
Specimen Collection
Arthrocentesis
Placement of needle in arthrocentesis of (A) elbow and
(B) knee joints.
CollectionThree samples are collected.
Note
If the specimen cannot be examined immediately, fluid should be frozen
and st...
Macroscopic Laboratory
Testing
Volume
Color and Clarity
Inclusions
Viscosity
Clotting
Mucin Clot
Laboratory Testing: Macroscopic
Volume
Normal up to <3.5 ml of fluid
Can reach up to 25 ml
Inflammation
Macroscopic Analysis: Color and Clarity
Colorless to pale yellow and clear
normal
Red, brown, or xanthochromic
 hemorr...
Macroscopic Analysis: Inclusions
Rice bodies.
Free-floating aggregates of tissue appear as
rice bodies.
rheumatoid arth...
Macroscopic Analysis: Viscosity
“Ropes” or “Mucin
Clot Test”
Normal = 4-6 cm
When 2-5% acetic acid
is added, normal
syn...
Macroscopic Analysis: Clotting
Normal synovial fluid: Do not clot
Clotting of synovial fluid = fibrinogen
1.Damaged syno...
Macroscopic Analysis: Mucin Clot
“Ropes test”
Estimation of hyaluronic acid–
protein complex integrity
The adding of ac...
Mucin Test
Good : solid clot
Fair: soft clot
Low: Friable clot
Poor: No clot
Microscopic Analysis: Cell Counts
Total leukocyte count
<200 cells/uL
Why is the traditional WBC
fluid not used for cell counting?
Because it contains
______________ which is
responsible for clotting.
Can clear undiluted fluid be
used for counting?
Microscopic Analysis: Cell
Counts
Neubauer Counting Chamber
Microscopic Analysis: Diff Count
Incubate with hyaluronidase
Neutrophils : <25% of the differential
Lymphocytes: <15%
...
Chemical Analysis: Protein
All proteins found in plasma
Exception: various high–molecular weight
proteins which may be p...
Chemical Analysis: Protein (cont.)
Normal range <3 g/dl
Increased protein
ankylosing spondylitis
arthritis
Crohn dise...
Chemical Analysis: Glucose
Compare to serum glucose levels
<10 mg/dL lower than blood glucose
Decreased – joint disorde...
Chemical Analysis: Uric Acid
Normal - 6 to 8 mg/dL
Increased – gout
May form crystals
Chemical Analysis: Lactic Acid
Rarely measured in synovial fluid
Can be helpful in diagnosing septic arthritis.
Normal ...
Laboratory Testing: Lactate Dehydrogenase
Elevated in synovial fluid
Normal in serum level
Increased in
Rheumatoid art...
Laboratory Testing: Rheumatoid Factor
RF is an antibody to immunoglobulins.
Present in rheumatoid arthritis:
Serum – mo...
Microscopic Analysis: Differential
LE cells
Neutrophils that have
engulfed a nucleus of
a lymphocyte
Tart cells
Monocy...
Microscopic Analysis: Differential
Reiter cells
Vacuolated macrophages
with ingested neutrophils
RA cells
“Ragocytes”
...
Microscopic Analysis: Differential
Hemosiderin
Seen in Pigmented
Villonodular Synovitis
Inclusions within clusters
of s...
Crystal Identification
Monosodium urate (MSU)
Calcium pyrophosphate (CPPD)
Crystal Identification
Corticosteroid
Cholesterol
Laboratory Testing: Microbiology
Staining
Smears prepared by centrifugation or
cytocentrifugation
Saline dilution reduc...
Classification of Joint Disorders
Classification of Joint Disorders
Group Classification Pathologic Significance
1. Noninflammatory Degenerative joint
disor...
Classification of Joint Disorders
3. Septic Microbial Infection
4. Hemorrhagic Traumatic injury, tumors,
hemophilia, other...
Review of Key Points
Synovial fluid analysis
Is a well-established procedure for evaluation of joint
disease.
Determine...
Thank you
Synovial fluid
Synovial fluid
Synovial fluid
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synovial fluid is the fluid which is present within the joint for lubrication, provide of nutrition, to prevent from shock. fluid analysis is very important in medical field for the diagnosis of many diseases, on the basis of which a patient may be properly treated.

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Synovial fluid

  1. 1. Muhammad Asif Zeb Lecture Hematology IPMS-KMU
  2. 2. Objective Physiology and Composition of Synovial Fluid Specimen Collection Laboratory Testing Macroscopic Evaluation Chemical Examination Microscopic Examination
  3. 3. Synovial Fluid Synovial syn(like) + ovia (egg) “Joint Fluid”
  4. 4. Synovial Fluid Viscous fluid found in the cavities of movable joints Synovial membrane Inner membrane of synovial joints Secretes synovial fluid into the joint cavity Contain specialized cells (synoviocytes)
  5. 5. Composition Hyaluronic acid synthesized by the synovial membrane increase the viscosity and elasticity of articular cartilages lubricate the surface between synovium and cartilage. Lubricin secreted by synovial cells. It is chiefly responsible for so called boundary layer lubrication, which reduces friction between opposing surfaces of cartilage.
  6. 6. Major Functions Reducing friction Lubrication Lessen shock Supplying oxygen and nutrients
  7. 7. Synovial Fluid: Specimen Collection
  8. 8. Bulge test The Bulge test is used to determine if there is an abnormal amount of fluid surrounding a joint Bulge test of joint for the detection of synovial effusion
  9. 9. Bulge Test
  10. 10. Specimen Collection Arthrocentesis Placement of needle in arthrocentesis of (A) elbow and (B) knee joints.
  11. 11. CollectionThree samples are collected. Note If the specimen cannot be examined immediately, fluid should be frozen and stored at -70°C until examined
  12. 12. Macroscopic Laboratory Testing Volume Color and Clarity Inclusions Viscosity Clotting Mucin Clot
  13. 13. Laboratory Testing: Macroscopic Volume Normal up to <3.5 ml of fluid Can reach up to 25 ml Inflammation
  14. 14. Macroscopic Analysis: Color and Clarity Colorless to pale yellow and clear normal Red, brown, or xanthochromic  hemorrhage into the joint Yellow/clear noninflammatory effusions Yellow/cloudy inflammation White/cloudy/milky Crystals
  15. 15. Macroscopic Analysis: Inclusions Rice bodies. Free-floating aggregates of tissue appear as rice bodies. rheumatoid arthritis (RA) Degenarated synovium enriched with fibrin Ochronotic shards debris from joint prosthesis look like ground pepper A =ochronotic shards
  16. 16. Macroscopic Analysis: Viscosity “Ropes” or “Mucin Clot Test” Normal = 4-6 cm When 2-5% acetic acid is added, normal synovial fluid will form a clot surrounded by clear fluid
  17. 17. Macroscopic Analysis: Clotting Normal synovial fluid: Do not clot Clotting of synovial fluid = fibrinogen 1.Damaged synovial membrane 2.Traumatic tap
  18. 18. Macroscopic Analysis: Mucin Clot “Ropes test” Estimation of hyaluronic acid– protein complex integrity The adding of acetic acid to normal synovial fluid, which causes clot formation. Criteria: Compactness of the clot Clarity of the supernatant fluid
  19. 19. Mucin Test Good : solid clot Fair: soft clot Low: Friable clot Poor: No clot
  20. 20. Microscopic Analysis: Cell Counts Total leukocyte count <200 cells/uL
  21. 21. Why is the traditional WBC fluid not used for cell counting?
  22. 22. Because it contains ______________ which is responsible for clotting.
  23. 23. Can clear undiluted fluid be used for counting?
  24. 24. Microscopic Analysis: Cell Counts Neubauer Counting Chamber
  25. 25. Microscopic Analysis: Diff Count Incubate with hyaluronidase Neutrophils : <25% of the differential Lymphocytes: <15% Crystal: None present Increase neutrophil: septic condition Increase cell count with increase lymphocyte: nonseptic inflammation
  26. 26. Chemical Analysis: Protein All proteins found in plasma Exception: various high–molecular weight proteins which may be present in very small amount Fibrinogen beta 2 macroglobulin alpha 2 macroglobulin Use common serum protein procedures
  27. 27. Chemical Analysis: Protein (cont.) Normal range <3 g/dl Increased protein ankylosing spondylitis arthritis Crohn disease Gout Psoriasis Reiter syndrome ulcerative colitis.
  28. 28. Chemical Analysis: Glucose Compare to serum glucose levels <10 mg/dL lower than blood glucose Decreased – joint disorders
  29. 29. Chemical Analysis: Uric Acid Normal - 6 to 8 mg/dL Increased – gout May form crystals
  30. 30. Chemical Analysis: Lactic Acid Rarely measured in synovial fluid Can be helpful in diagnosing septic arthritis. Normal = less than 25 mg/dL Septic arthritis can show levels up to 1000 mg/dL
  31. 31. Laboratory Testing: Lactate Dehydrogenase Elevated in synovial fluid Normal in serum level Increased in Rheumatoid arthritis (RA) infectious arthritis gout Neutrophils increased during the acute phase of these disorders contribute to this increased LD.
  32. 32. Laboratory Testing: Rheumatoid Factor RF is an antibody to immunoglobulins. Present in rheumatoid arthritis: Serum – most cases Synovial fluid - 50% Rarely elevated only in synovial fluid and not serum False positives in other chronic inflammatory diseases.
  33. 33. Microscopic Analysis: Differential LE cells Neutrophils that have engulfed a nucleus of a lymphocyte Tart cells Monocytes that have engulfed nuclear material
  34. 34. Microscopic Analysis: Differential Reiter cells Vacuolated macrophages with ingested neutrophils RA cells “Ragocytes” Neutrophils with small, dark, cytoplasmic granules that consist of precipitated rheumatoid factor
  35. 35. Microscopic Analysis: Differential Hemosiderin Seen in Pigmented Villonodular Synovitis Inclusions within clusters of synovial cells Rice bodies Macroscopically resemble polished rice Microscopically show collagen and fibrin
  36. 36. Crystal Identification Monosodium urate (MSU) Calcium pyrophosphate (CPPD)
  37. 37. Crystal Identification Corticosteroid Cholesterol
  38. 38. Laboratory Testing: Microbiology Staining Smears prepared by centrifugation or cytocentrifugation Saline dilution reduces clustering of cells Gram’s stain most common Culture Set up with positive or negative stain results Aerobic anaerobic
  39. 39. Classification of Joint Disorders
  40. 40. Classification of Joint Disorders Group Classification Pathologic Significance 1. Noninflammatory Degenerative joint disorders, osteoarthritis 2. Inflammatory Immunologic Disorders, RA, Scleroderma, Polymyositis, ankylylosing spondylitis, rheumatic fever, Lyme arthritis, Crystal-induced gout, pseudogout
  41. 41. Classification of Joint Disorders 3. Septic Microbial Infection 4. Hemorrhagic Traumatic injury, tumors, hemophilia, other coagulation disorders, anticoagulant overdose
  42. 42. Review of Key Points Synovial fluid analysis Is a well-established procedure for evaluation of joint disease. Determines the presence of arthritis Assists in the classification of joint disorders Helps guides appropriate treatments
  43. 43. Thank you
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synovial fluid is the fluid which is present within the joint for lubrication, provide of nutrition, to prevent from shock. fluid analysis is very important in medical field for the diagnosis of many diseases, on the basis of which a patient may be properly treated.

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