SYNOVIAL FLUID (SYNOVIA) Joints are articulations between

bones. Freely movable joints are composed of hyaline articular

cartilage and a fibrous capsule that is lined on its inner surface by
a membrane (Fig. 46-4). Synovial fluid fills the joint cavity and acts
as a lubricant, to minimize the friction between bones during
movement or weight bearing. This fluid also provides the sole
nutrition for cartilage. Synovial fluid enters the cartilage by
diffusion and through a spongelike effect when the carti- lage is
compressed and relaxed. The term synovia, coined by Paracelsus, is
derived from the Greek syn (“with”), along with oon (from the Latin
ovum, meaning “egg”) and -ia (probably “condition”), suggesting
the fluid’s resemblance to raw egg white. Synovial fluid is a
dialysate of plasma that is mixed with hyaluronic acid.
Ultrafiltration by the rich vascular network in the synovial tissue
produces this fluid, whereas hyaluronic acid, a mucoprotein, is
secreted into the dialysate by synovial cells. Synovial lining Fibrous
capsule Ligament Joint cavity toe yaline cartilage Fig. 46-4
Diagram of normal synovial joint. (From Beck EW: Mosby’s Atlas of
Functional Human Anatomy, St Louis, 1982, Mosby. Courtesy of
Ernest Beck.) Normal Synovial Fluid The fluid volume in the normal
joint depends on the size of the structure. The knee joint usually
contains 0.1 to 3.5 mL of fluid.* Normal synovial fluid is clear or
pale yellow with a specific gravity close to that of plasma. The
viscosity is high relative to that of water because of protein
complexes with the polysaccharide, hyaluronic acid; these
complexes constitute 99% of the mucoproteins present in the fluid.
Hyaluronic acid, a long-chain, high-molecular-weight polymer made
up of repeating units of acetylglucosamine and glucuronic acid, is
destroyed in inflammatory states by hyaluronidase, an enzyme that
is contained in neutrophils. When this occurs, fluid vis- cosity
decreases significantly, giving the clinician a bedside test for the
presence of inflammatory fluid. Synovial protein concentrations are
related to the molecu- lar weight of each protein because of the
molecular sieving effect in the synovia. Thus, albumin is present in
relatively higher concentrations than are the higher-molecular-
weight globulins. Fibrinogen is not present because of its high
molec- ular weight, so normal synovium does not coagulate.
Glucose and uric acid diffuse freely into the synovia, and in the
fasting state are as concentrated in synovia as in plasma. The
characteristics of normal synovia are summarized in Table 46-3.°*
Change of Analyte in Disease Physical and chemical changes that
occur in the synovia during disease reflect basic pathological
processes that occur in the joint. A pathological classification of
synovial fluids and the diseases associated with each category are
summarized in Table 46-4. The laboratory tests discussed in this
section CHAPTER 46 Extravascular Biological Fluids include
viscosity, fibrinogen, total protein, complement, glucose, uric acid,
and the number and composition of white blood cells, as well as the
percentage of neutrophils. In addi- tion, crystal indentification and
microbiological tests (gram 901 Normal synovia contain no
fibrinogen, but because inflam- stain and culture) are needed to
complete examination of the fluid. Clinically, there is no need for a
sophisticated measurement of viscosity. Instead, this may be
measured at the time of aspiration by placing a finger at the tip of
the syringe and stringing out the fluid. Noninflammatory fluids will
“string out” longer than 4 cm. An alternative method is to drip fluid
off the needle and syringe and observe it. Generally, if the fluid
strings, it is a noninflammatory fluid; if it drips similar to water, the
fluid is the result of inflammation. The depolymer- ization of
hyaluronic acid by neutrophil hyaluronidase decreases the viscosity
in inflammatory disease. Table 46-3 Volume, mL* Physical and
Chemical Characteristics of Normal Synovia Relative viscosity at
38°C Hyaluronic acid, g/L Total protein, g/dL Immunoglobulins,
mg/dL IgG IgA IgM Fibrinogen, mg/L Complement, CHs) U/mL
Glucose, mg/dL Uric acid, mg/dL Mean iil 235 3600 ho 453 74 37 0
20' x ‘ Ig, Immunoglobulin. CHs9, total (hemolytic) complement.
*Knee. tValues are approximately 10% of plasma values. *Fasting
values are similar to plasma values. Table 46-4 Range DIS 1O BS
5.7 to 1160 1700 to 4050 1.0 to 221 33 to 850 27 to 177 0 to 84 0
16 to 25 65 to 120 2 5ito\ 7-2 matory synovitis permits the passage
of high-molecular- weight proteins into the fluid, fibrinogen can be
present, and spontaneous clotting can occur; clot size is roughly
propor- tionate to the degree of inflammation. Thus anticoagulants
are necessary when specimens are collected for microscopic and
bacteriological examination. In synovia, unlike in serous fluids,
total protein concentra- tion is not used to distinguish
noninflammatory from inflam- matory fluids, because the leukocyte
count is used to make that distinction. Thus, total protein is not
included in the routine examination of synovial fluids; however, its
measure- ment can be helpful for interpreting complement levels.”
Complement proteins usually are present at lower concen- trations
in synovial fluid than in serum. In systemic inflam- matory
conditions, complement behaves as an acute-phase reactant, and
hypercomplementemia occurs. In some condi- tions, such as
Reiter’s disease, the joint fluid complement con- centration has
been reported to be even higher than that of serum. In systemic
immune complex diseases such as systemic lupus erythematosus
(SLE), complement is consumed widely and can be low in both
serum and synovial fluid. In other diseases, such as rheumatoid
arthritis and viral synovitis, complement is consumed locally in the
synovia, whereas serum levels are usually normal or high. In
rheumatoid arthri- tis, synovial fluid complement levels generally
are low, and many types of immunoglobulins are present. The
proper approach to interpreting complement levels in synovia is
con- troversial. For practical purposes, compare synovia versus
serum complement levels, and consider synovium comple- ment low
if it is less than 30% of serum levels. However, in SLE and other
severe immune complex diseases, both levels may be low. In such a
situation, one can compare synovium and serum complement levels
versus total protein in each fluid. Interpretation of synovial glucose
levels requires knowl- edge of the patient’s simultaneous serum
glucose.