Synovial Fluid Analysis

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1

joint space

lined by a synovial membrane and synovial fluid bathes and lubricates joints; present where friction can develop

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synoviocytes

lines joint space; actively phagocytic and synthesizes degradative enzymes such as collagenases

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hyaluronate

a mucopolysaccharide linked with a protein

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synovial fluid

formed by ultrafiltration of plasma across synovial membrane and from secretions by synoviocytes

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glucose and uric acid

synovial fluid composition same as plasma

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total protein and immunoglobulins

synovial fluid composition that varies from 1/4 to 1/2 that of plasma

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noninflammatory, inflammatory, septic, and hemorrhagic

four principle categories of joint disorders

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arthrocentesis

percutaneous aspiration from a joint using aseptic technique and disposable sterile equipment

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0.1 to 3.5 mL

normal fluid volume of arthrocentesis

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no anticoagulant tube for chemical and immunologic studies

tube #1

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anticoagulant tube for microscopic studies

tube #2

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sterile anticoagulant tube for microbiological studies

tube #3

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sodium heparin and EDTA

best anticoagulants since they do not form crystals

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sodium polyanetholesulfonate (SPS)

acceptable for microbiological studies

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room temperature

temperature to transport and analyze (to be analyzed immediately)

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pale yellow or colorless and clear

normal color

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red or brown

associated with trauma during collection procedure or disorders that disrupt synovial membrane allowing blood to enter joint

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greenish or purulent

associated with infections

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milky

associated with TB arthritis and SLE

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WBCs, RBCs, and synoviocytes

cells present in synovial fluid

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crystals, fat droplets, fibrin, cellular debris, and rice bodies

substances seen in synovial fluid

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rice bodies

white, free-floating substances made up of collagen covered by fibrinous tissue

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rheumatoid arthritis and other arthritis

conditions rice bodies are seen in

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high viscorsity

caused by high concentration of mucoprotein hyaluronate

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spontaneous clot formation

indicates abnormal presence of fibrinogen

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normal saline

used as diluent if necessary

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hyaluronidase buffer

may be used as diluent if necessary to reduce viscosity for more efficient counting

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less than 2000/uL

normal RBC count sometimes increased from traumatic tap or hemorrhagic effusions

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less than 200/uL

normal WBC count somtimes increased due to bacterial arthritis

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monocytes and macrophages

60% of WBCs in synovial fluid

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lymphocytes

30% of WBCs in synovial fluid

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neutrophils

10% of WBCs in synovial fluid

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bacterial arthritis and urate gout

possible diagnosis when more than 80% neutrophils are seen in synovial fluid

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polarized microscopy

should be used to identify crystals of monosodium urate and calcium pyrophosphate dihydrate CCPD

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monosodium urate crystals

present in gouty arthritis; needle-like crystals with pointed ends that can distend the cytoplasm of WBCs; strongly birefringent; bright against dark background resembling toothpicks

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calcium pyrophosphate dihydrate crystals

seen in degenerative arthritis and arthritis accompanying metabolic diseases; rodlike or rhomboid; smaller and more blunt and less birefringent

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cholesterol

observe on wet prep or unstained cytospin slide; flat, rectangular plates with notched corners; seen in chronic inflammation

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hydroxyapatite

observe intracellularly only using electron microscope; tiny, needle like crystals; can induce acute inflammatory reaction similar to that caused by MSU and CPPD crystals

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corticosteroids

seen for months after steroid injections; no clinical significance; look like MSU or CPPD but yield conflicting results based on their birefringence

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glucose

some diseases cause decreased glucose in fluid, 1/2 that present in the patient's plasma

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total protein

increased protein as a result of variety of joint diseases; only indicates inflammatory process

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uric acid

same levels as plasma; increased levels in fluid may cause MSU crystals

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lactate

increased from anaerobic glycolysis in the synovium; clinical value not yet established

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culture

analysis that should be performed on all synovial fluid samples