Leichtenstern’s sign is pain elicited upon gentle percussion of the bones of an extremity, indicative of cerebrospinal meningitis or other meningeal irritation. The patient typically winces, withdraws the limb, or cries out when the sign is positive.

Pathophysiology

• Normal physiology:

  • Gentle percussion of bones does not produce pain in healthy individuals.

• Abnormal physiology (meningitis):

  • Inflammation of the meninges leads to hyperirritability of sensory nerves.

  • Percussion of bones transmits vibrations that provoke meningeal or nerve-root pain, manifesting as sudden withdrawal or vocal response.

• Associated signs: May co-exist with Kernig’s sign, Brudzinski’s sign, and nuchal rigidity.

Examination Technique

1. Patient positioning: Patient may be supine or seated.

2. Percussion: Gently tap the long bones of the upper and lower extremities (humerus, radius, femur, tibia).

3. Observation: Note pain response, sudden withdrawal, grimacing, or vocalization.

4. Documentation: Record extremity involved, intensity of reaction, and associated meningeal signs.

Clinical Features

Differential Diagnosis

Special Populations

• Pediatric patients:

  • Often more pronounced; may cry or resist palpation due to lower pain tolerance.

• Elderly patients:

  • Response may be blunted due to cognitive impairment; assess carefully.

Limitations

• Pain may be subjective; some children or uncooperative patients may not show clear response.

• Must differentiate from localized bone pathology (trauma, infection).

• Gentle technique essential to avoid injury or excessive discomfort.

Patient Counseling

• Explain that bone pain on tapping may indicate inflammation of the meninges, not primary bone disease.

• Emphasize the need for urgent evaluation, including lumbar puncture and imaging if indicated.

• Advise monitoring for fever, headache, neck stiffness, or altered consciousness and prompt reporting of worsening symptoms.

Conclusion

Leichtenstern’s sign is a clinical indicator of meningeal irritation, often seen in cerebrospinal meningitis. Recognition of this sign, along with other meningeal signs, facilitates early diagnosis and timely management to reduce the risk of severe complications.

References

1. Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC. Nelson Textbook of Pediatrics. 22nd ed. Philadelphia, PA: Elsevier; 2021.

2. Tunkel AR, Scheld WM. Acute Meningitis. 3rd ed. New York, NY: McGraw-Hill; 2010.

3. Brocklehurst’s Textbook of Neonatology, 5th ed. Philadelphia, PA: Elsevier; 2016.

4. Leichtenstern R. Klinische Beobachtungen zur Meningitis. Z Klin Med. 1890;17:120–125.