Diseases (12)
Diagnostic Testing (12)

Note:

Reflex to culture if elevated WBC and no crystals or bacteria are seen.


Note:

If joined inflammation and aspiration required.


Note:

If arthritis present


Note:

If joints are involved.


Note:

If arthritis present are involved.


Note:

If obtained, the synovial fluid in Neuropathic arthropathy is clear, sterile and lack crystals.

Overview

Synovial fluid analysis is utilized to diagnose the cause of pain, swelling, and fluid collection in the joints. The joints that are most commonly affected are the knee, hip, and shoulder joints. The conditions that affect the synovial fluid can be broken down into five general categories. These disease categories are Non-Inflammatory disease, Inflammatory disease, Infectious disease, Degenerative disease, and Bleeding disorders. Non-inflammatory diseases that are associated with synovial fluid involvement include trauma, sickle cell disease, and CPPD crystal deposition disease (pseudogout). Inflammatory diseases associated with synovial fluid include autoimmune disorders such as systemic lupus erythematosus, psoriasis, and rheumatoid arthritis as well as gout. Infectious arthritis is usually acute bacterial in nature. The most common causative organism in some studies is Neisseria gonnorrhea following by Staphylococcus aureus. Chronic septic arthritis is rare and reported causative organisms include Mycobacterium tuberculosis and Candida albicans. Bleeding disorders that lead to blood in the synovial fluid typically involve individuals with blood clotting disorders such as hemophilia, von Willenbrand’s disease, Glanzmann’s thrombasthenia, and synovial tumors as well as injuries. Degenerative disorders include primarily osteoarthritis which causes erosion of the joint surfaces and accumulation of fibrin.

The most important reason to perform an analysis on synovial fluid is to rule out septic arthritis. Analysis of synovial fluid is rarely needed in pediatric patients, but is used primarily to differentiate between inflammatory and non-inflammatory disease states. Analysis of synovial fluid usually includes multiple studies such as cell count, microscopic analysis, culture, examination for crystals, and other chemical analysis.

Clinical Utility
  • Diagnosis of joint disease such as gout and traumatic arthritis
  • Differential diagnosis of traumatic arthritis from the immune-based and crystal-induced arthritis
  • As an aid in diagnosis of joint disease due to inflammation and infection
  • Aid in diagnosis of joint injury

Interpretation

Abnormal in:

  • Gout (uric acid)
  • Pseudogout (calcium pyrophosphate deposition disease)
  • Rheumatoid arthritis
  • Infectious arthritis (lactate dehydrogenase)
  • Immune-based arthritis
  • Bacterial infection (protein)
  • Joint injury
  • Lower than normal viscocity is associated with inflammation
  • Decreased clarity (cloudy SF) may indicate crystals, WBCs, or microorganisms in the fluid
  • Reddish SF indicates red blood cells in the fluid which can indicate bleeding disorders
  • Decreased glucose is associated with inflammation but compare with serum glucose

Reference Ranges
  Normal Pathological Normal Pathological
Volume, mL (knee): <4 >4 <0.004 L >0.004 L
Viscosity        
String test + (high) - (low)    
Mucin clot Firm Friable    
Clarity Clear Cloudy    
Color Straw Red    
Cell counts        
WBC (u/L) <200 >2000 <0.2 x 10^9/L >2 x 10^9/L
         
  Percent of total   Fraction of total  
PMN <25 >75   <0.25 >0.75  
RBC <2 >50   <0.02 >0.50  
Chemistry        
Total protein (g/dL) 1.2-3.0 >4.0 12-30 g/L >40 g/L
Glucose (mg/dL) Serum level <60   Serum level 3.4 mmol/L


 

 

Methodology

Visual examination, cell count and differential, polarizing microscopic exam for crystals, Gram stain, AFB smear and culture, Culture and susceptibility testing.

Specimen Collection

Synovial fluid aspirate. EDTA (Lavender) preferred, or Heparin (Green) acceptable.

  • Ideally 15 mL divided into two sodium heparin tubes and one sterile tube without additives.
  • Ambient: 48 hours
  • Refrigerated: 48 hours

Additional Testing

Blood/urine uric acid, Blood glucose, Joint bacterial mycobacterial and fungal cultures as indicated, Blood cultures if systemic infection is suspected, ANA, CBC with differential, ESR, C-reactive protein.

CPT
83872$5.86
84157$4$4
89051$5.6
89060$7.33

ICD10
ICD CODE AND DESCRIPTIONLCD CODENCD CODE
A68 - Relapsing fevers
A78 - Q fever
E08.610 - Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy
E09.610 - Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy
E10.610 - Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E11.610 - Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E13.610 - Other specified diabetes mellitus with diabetic neuropathic arthropathy
E79 - Disorders of purine and pyrimidine metabolism
G73.7 - Myopathy in diseases classified elsewhere
I00 - Rheumatic fever without heart involvement
I01 - Rheumatic fever with heart involvement
I01.0 - Acute rheumatic pericarditis
I01.1 - Acute rheumatic endocarditis
I01.2 - Acute rheumatic myocarditis
I01.8 - Other acute rheumatic heart disease
I01.9 - Acute rheumatic heart disease, unspecified
I09 - Other rheumatic heart diseases
I09.9 - Rheumatic heart disease, unspecified
I25 - Chronic ischemic heart disease
I32 - Pericarditis in diseases classified elsewhere
I39 - Endocarditis and heart valve disorders in diseases classified elsewhere
I41 - Myocarditis in diseases classified elsewhere
I51 - Complications and ill-defined descriptions of heart disease
I51.9 - Heart disease, unspecified
J99 - Respiratory disorders in diseases classified elsewhere
M00 - Pyogenic arthritis
M00.9 - Pyogenic arthritis, unspecified
M01 - Direct infections of joint in infectious and parasitic diseases classified elsewhere
M02 - Postinfective and reactive arthropathies
M02.3 - Reiter's disease
M02.30 - Reiter's disease, unspecified site
M02.829 - Other reactive arthropathies, unspecified elbow
M04.1 - Periodic fever syndromes
M05 - Rheumatoid arthritis with rheumatoid factor
M06 - Other rheumatoid arthritis
M06.9 - Rheumatoid arthritis, unspecified
M08 - Juvenile arthritis
M08.0 - Unspecified juvenile rheumatoid arthritis
M08.1 - Juvenile ankylosing spondylitis
M08.3 - Juvenile rheumatoid polyarthritis (seronegative)
M08.80 - Other juvenile arthritis, unspecified site
M08.90 - Juvenile arthritis, unspecified, unspecified site
M08.99 - Juvenile arthritis, unspecified, multiple sites
M10 - Gout
M10.0 - Idiopathic gout
M10.00 - Idiopathic gout, unspecified site
M10.1 - Lead-induced gout
M10.10 - Lead-induced gout, unspecified site
M10.2 - Drug-induced gout
M10.4 - Other secondary gout

Additional ICD10
ICD CODE AND DESCRIPTIONLCD CODENCD CODE
A68.0 - Louse-borne relapsing fever
A68.1 - Tick-borne relapsing fever
A68.9 - Relapsing fever, unspecified
E79.0 - Hyperuricemia without signs of inflammatory arthritis and tophaceous disease
E79.1 - Lesch-Nyhan syndrome
E79.2 - Myoadenylate deaminase deficiency
E79.8 - Other disorders of purine and pyrimidine metabolism
E79.9 - Disorder of purine and pyrimidine metabolism, unspecified
I01.0 - Acute rheumatic pericarditis
I01.1 - Acute rheumatic endocarditis
I01.2 - Acute rheumatic myocarditis
I01.8 - Other acute rheumatic heart disease
I01.9 - Acute rheumatic heart disease, unspecified
I09.0 - Rheumatic myocarditis
I09.1 - Rheumatic diseases of endocardium, valve unspecified
I09.2 - Chronic rheumatic pericarditis
I09.8 - Other specified rheumatic heart diseases
I09.81 - Rheumatic heart failure
I09.89 - Other specified rheumatic heart diseases
I09.9 - Rheumatic heart disease, unspecified
I25.1 - Atherosclerotic heart disease of native coronary artery
I25.10 - Atherosclerotic heart disease of native coronary artery without angina pectoris
I25.11 - Atherosclerotic heart disease of native coronary artery with angina pectoris
I25.110 - Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
I25.111 - Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm
I25.118 - Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119 - Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
I25.2 - Old myocardial infarction
I25.3 - Aneurysm of heart
I25.4 - Coronary artery aneurysm and dissection
I25.41 - Coronary artery aneurysm
I25.42 - Coronary artery dissection
I25.5 - Ischemic cardiomyopathy
I25.6 - Silent myocardial ischemia
I25.7 - Atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris
I25.70 - Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris
I25.700 - Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris
I25.701 - Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm
I25.708 - Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris
I25.709 - Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris
I25.71 - Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris
I25.710 - Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris
I25.711 - Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.718 - Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris
I25.719 - Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris
I25.72 - Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris
I25.720 - Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris
I25.721 - Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.728 - Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris
I25.729 - Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris

References
  • Best Pract Res Clin Rheumatol. 2009 Apr;23(2):161-92. [PMID:19393565]
  • J Emerg Med. 2006 Apr;30(3):331-9. [PMID:16677989]
  • Ann Rheum Dis. 2002 Jun;61(6):493-8. [PMID:12006320]
  • Best Pract Res Clin Rheumatol. 2005 Jun;19(3):371-86. [PMID:15939364]
  • Alan Wu. Tietz Clinical Guide to Laboratory Tests, Fourth Edition. Saunders; 4 edition (June 13, 2006). ISBN-10: 0721679757