Abstract
Summary A case of peripheral gangrene of the leg following an intramuscular penicillin injection into the midlateral thigh of an infant is reported. Although this site has proved superior for intramuscular injections in infants and young children, there are potential dangers. An analysis of this case suggests that, for pediatric practice, the 1 1/2 inch, 20 gauge needle usually provided in standard injection sets be replaced by a 1 inch needle. Care must also be taken to limit the injection site to the upper outer quadrant of the thigh, and the needle should be inserted obliquely to avoid any major nerves or vessels.
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