Is it safe to inject vaccines in the upper lateral aspect of the gluteal (buttock) region?

Vaccine Administration in the Gluteal Region

The buttock region should not be used routinely for vaccine administration due to the risk of sciatic nerve injury and decreased immunogenicity of vaccines. 1

Risks of Gluteal Injections

• The Advisory Committee on Immunization Practices (ACIP) specifically advises against using the buttock for routine vaccination of infants, children, or adults due to potential risk of injury to the sciatic nerve 1
• Injection into the buttock has been associated with decreased immunogenicity of hepatitis B and rabies vaccines in adults, likely due to inadvertent subcutaneous injection or injection into deep fat tissue rather than muscle 1
• Sciatic nerve injury following gluteal injections can result in complications ranging from minor transient pain to severe sensory disturbance and motor loss with poor recovery 2, 3

When Gluteal Injections Are Necessary

If the buttock must be used (e.g., for passive immunization when large volumes are required or multiple doses are necessary, such as with immune globulin):

• Only the upper, outer quadrant should be used 1
• The central region of the buttock must be avoided 1
• The needle should be directed anteriorly (not inferiorly or perpendicular to the skin) to minimize the possibility of sciatic nerve involvement 1
• The ventrogluteal region (gluteal triangle) has a more favorable safety profile than the dorsogluteal region when gluteal injection is absolutely necessary 3

Preferred Injection Sites for Vaccines

For Adults:

• The deltoid muscle is the recommended site for routine intramuscular vaccination 1, 4, 5
• Use a 1-1½ inch, 22-25 gauge needle for adults 1, 4
• The mid-point of the deltoid muscle (midway between the acromion and the deltoid tuberosity) with the arm abducted to 60° is a safe site for injection 6

For Children:

• For toddlers and older children, the deltoid muscle can be used if muscle mass is adequate 1
• The anterolateral aspect of the thigh is recommended for infants and young children 1, 4
• Needle size for children should range from 22-25 gauge and 7/8 to 1¼ inches, based on muscle size 1, 4

Proper Injection Technique

• For all intramuscular injections, the needle should be long enough to reach the muscle mass but not so long as to involve underlying nerves, blood vessels, or bone 1
• Before injecting, pull back on the plunger to check for blood return; if blood appears, withdraw and select a new site 4
• Insert the needle at a 90-degree angle for intramuscular injections 4
• A needle penetration depth of 12.7 mm (0.5 inches) has been shown to achieve 100% of injections into the deltoid muscle in adults 7

Common Pitfalls to Avoid

• Improper site selection in the gluteal region can lead to sciatic nerve injury, which may cause foot drop and other neurological deficits 2, 3
• Inadequate needle length can result in subcutaneous rather than intramuscular administration, potentially reducing vaccine efficacy 1
• Improper deltoid injection technique can lead to upper arm injury related to vaccine administration (UAIRVA), affecting structures like the subdeltoid/subacromial bursa or axillary nerve 6, 8
• Injecting too high in the deltoid can risk injury to the axillary nerve and too low can risk radial nerve injury 6