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Synovial fluid analysis
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  1. 1. Chapter Outline Physiology and Composition of Synovial Fluid Specimen Collection Laboratory Testing Macroscopic Evaluation Chemical Examination Microscopic Examination Classification of Joint Disorders
  2. 2. Synovial Fluid Synovial syn(like) + ovia (egg) “Joint Fluid”
  3. 3. Synovial Fluid Viscous fluid found in the cavities of movable joints (diarthroses) Synovial membrane Inner membrane of synovial joints Secretes synovial fluid into the joint cavity Contain specialized cells (synoviocytes)
  4. 4. 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.
  5. 5. What do you call the damage to the articular membranes producing stiffness and pain in the joints?
  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. Macroscopic Laboratory Testing Volume Color and Clarity Inclusions Viscosity Clotting Mucin Clot
  12. 12. Laboratory Testing: Macroscopic Volume Normal up to <3.5 ml of fluid Can reach up to 25 ml Inflammation
  13. 13. 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 Deeper yellow Non inflammatory and inflammatory effusions
  14. 14. 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 B =rice bodies
  15. 15. 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
  16. 16. A medical technologist received 2 clear, thick and viscous samples labelled A and B. He added 2% acetic acid, sample A did not clot while sample B did. Which of the following is suggestive of synovial fluid? The other sample may possibly be?
  17. 17. When sufficient blood is collected, it should be distributed in what color of tubes?
  18. 18. Sterile heparinized = GS/CS Heparin / EDTA = cell count Noncoagulated tube = other tests Sodium fluoride = Glucose
  19. 19. Macroscopic Analysis: Clotting Normal synovial fluid: Do not clot Clotting of synovial fluid = fibrinogen 1.Damaged synovial membrane 2.Traumatic tap
  20. 20. 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
  21. 21. Mucin Test Good : solid clot Fair: soft clot Low: Friable clot Poor: No clot
  22. 22. Macroscopic Analysis: Cell Counts Total leukocyte count <200 cells/uL Very viscous fluid Pinch of hyaluronidase + 0.5 ml fluid 1 gtt 0.05% hyaluronidase in phosphate buffer per ml of fluid (incubate 37oC for 5 minutes)
  23. 23. Macroscopic Analysis: Cell Counts Diluents: Saline 0.3% hypotonic solution Saline that contains saponin
  24. 24. Why is the traditional WBC fluid not used for cell counting?
  25. 25. Because it contains ______________ which is responsible for clotting.
  26. 26. Can clear undiluted fluid be used for counting?
  27. 27. Macroscopic Analysis: Cell Counts Neubauer Counting Chamber
  28. 28. Macroscopic 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
  29. 29. 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
  30. 30. Chemical Analysis: Protein (cont.) Normal range <3 g/dl Increased protein ankylosing spondylitis arthritis Crohn disease Gout Psoriasis Reiter syndrome ulcerative colitis.
  31. 31. Chemical Analysis: Glucose Compare to serum glucose levels <10 mg/dL lower than blood glucose Decreased – joint disorders >20mg/dl decrease - infection
  32. 32. Chemical Analysis: Uric Acid Normal - 6 to 8 mg/dL Increased – gout May form crystals
  33. 33. 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
  34. 34. 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.
  35. 35. 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.
  36. 36. Microscopic Analysis: Differential LE cells Neutrophils that have engulfed a nucleus of a lymphocyte Tart cells Monocytes that have engulfed nuclear material
  37. 37. 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
  38. 38. Microscopic Analysis: Differential Hemosiderin Seen in Pigmented Villonodular Synovitis Inclusions within clusters of synovial cells Rice bodies Macroscopically resemble polished rice Macroscopically show collagen and fibrin
  39. 39. Microscopic Analysis: Differential Fat droplets Refractile intracellular and extracellular globules Stain with Sudan Dye
  40. 40. Crystal Identification Monosodium urate (MSU) Calcium pyrophosphate (CPPD)
  41. 41. Crystal Identification Corticosteroid Cholesterol
  42. 42. Crystal Identification Calcium oxalate Apatite (Ca Phosphate)
  43. 43. 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
  44. 44. Classification of Joint Disorders
  45. 45. Classification of Joint Disorders Group Classification Pathologic Significance 1. Noninflammatory Degenerative joint disorders, osteoarthritis 2. Inflammatory Immunologic Disorders, RA, LE, Scleroderma, Polymyositis, ankylylosing spondylitis, rheumatic fever, Lyme arthritis, Crystal-induced gout, pseudogout
  46. 46. Classification of Joint Disorders 3. Septic Microbial Infection 4. Hemorrhagic Traumatic injury, tumors, hemophilia, other coagulation disorders, anticoagulant overdose
  47. 47. Laboratory Findings 1. Noninflammatory Clear, yellow fluid Good viscosity WBCs <1000 uL Neutrophils <30% Normal glucose (similar to blood glucose)
  48. 48. Laboratory Findings 2. Inflammatory Immunologic origin Crystal - induced  Cloudy, yellow fluid Cloudy, yellow fluid  Poor viscosity Low viscosity  WBCs 2,000 – 75,000 uL up to 100,000 uL  Neutrophils >50% <70%  Decrease glucose level Decreased glucose level  autoantibodies present Crystals present
  49. 49. Laboratory Findings 3. Septic Cloudy yellow-green fluid Variable viscosity WBCs 50,000 – 100,000 uL Neutrophils > 75% Decreased glucose level Positive culture and gram stain
  50. 50. Laboratory Findings 4. Hemorrhagic Cloudy, red fluid Low viscosity WBCs equal to blood Neutrophils equal to blood Normal Glucose level
  51. 51. 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
  52. 52. Thank you
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