Is a tetanus (lockjaw) injection in the gluteal region acceptable?

Tetanus Injection Site: Deltoid Muscle Preferred Over Gluteal Region

Tetanus injections should not be administered in the gluteal region and should preferably be given in the deltoid muscle of the upper arm. 1, 2

Recommended Injection Sites for Tetanus Vaccines

• The Centers for Disease Control and Prevention (CDC) specifically recommends that tetanus-containing vaccines (Tdap) for adolescents and adults should be administered as a 0.5 mL dose, intramuscularly, preferably into the deltoid muscle 2, 3
• For children under 3 years, the anterolateral aspect of the thigh is the preferred site for tetanus-containing vaccines 2
• For children 3 years and older, adolescents, and adults, the deltoid muscle is the recommended site 2, 4

Why the Gluteal Region Should Be Avoided

• The FDA drug label for tetanus immune globulin explicitly states: "The gluteal region should not be used as an injection site because of the risk of injury to the sciatic nerve" 1
• The dorsogluteal site (buttock) presents significant safety concerns due to its proximity to neurovascular structures 5
• Measurements in cadaver studies show that the dorsogluteal region is closer to neurovascular structures (specifically the superior gluteal artery and nerve) compared to other injection sites, increasing risk of injury 5

Anatomical Considerations and Safety

• When administering intramuscular injections, proper technique is crucial to minimize adverse events 3, 2
• The deltoid muscle provides adequate muscle mass for absorption while maintaining a safer distance from major neurovascular structures 2, 4
• If multiple vaccines are needed during the same visit, they should be administered using separate syringes at different anatomic sites 3
• Some experts recommend administering no more than two injections per muscle, separated by at least one inch 3

Special Considerations

• Healthcare providers should always draw back on the plunger of the syringe before injection to ensure the needle is not in a blood vessel 1
• Proper needle length selection is important to ensure the vaccine reaches the intended muscle tissue 2
• Providers should consider observing patients for 15 minutes after vaccination to monitor for syncope (fainting), which may be more common in adolescents and young adults 2

Alternative Sites When Deltoid Is Unavailable

• If the deltoid muscle cannot be used for some reason, the anterolateral thigh is an acceptable alternative site for adults 2
• The ventrogluteal area (hip region) has been studied as a potentially safer alternative to the dorsogluteal site, as it is farther from neurovascular structures 5, 6
• However, current guidelines still strongly favor the deltoid muscle for adult tetanus vaccinations 2, 3