Tetanus can be administered subcutaneously

Deltoideus and Alternatives

Topic vaccination centers: What alternatives are there to the deltoid muscle? Why was the earlier standard "Glutaeus maximus" abandoned? Where do you vaccinate small children in whom the deltoid is not yet sufficiently developed?

Vaccinations: questions and answers
Hardly any other field of medicine raises as many questions as the subject of "vaccinations and vaccines". The STIKO recommendations sometimes leave room for interpretation. In addition, the individual constellations are so diverse that uncertainties are almost inevitable - be it about questionable vaccinations, vaccination intervals, vaccination reactions, dosages or indications, and, and, and. This new series deals with specific questions about vaccinations that our expert Dr. med. Andreas Leischker answered expertly.

There are vaccines that can be given both intramuscularly and subcutaneously (e.g. some vaccines for seasonal influenza), while other vaccines are intended to be given intramuscularly only.

Adequate muscle mass is required for safe intramuscular injection. Vaccines with adjuvants in particular can cause painful inflammation and the formation of granulomas if the vaccine reaches the subcutaneous fat tissue instead of the muscle tissue. With some vaccines, the success of the vaccination may also be less when given subcutaneously. The injection site should also be selected so that neither nerves nor larger blood vessels are hit.

Deltoideus as the first choice

For vaccines to be administered intramuscularly, the deltoid muscle is the preferred injection site for adolescents and adults:

The injection is made three cross fingers below the acromion perpendicular to the skin surface into the highest elevation of the deltoid muscle. A maximum of 2 ml of solution for injection should be injected into the deltoid muscle.

The current STIKO recommendations contain recommendations for needle length for the first time:

  • Adolescents and adults: 20 - 50 mm
  • Infants> 2 months and children: 25 mm
  • Infants <2 months: 15 mm

Contrary to previous recommendations, aspiration should not be performed before injecting vaccines intramuscularly. This applies to all age groups. There is no need for aspiration as there are no large blood vessels at the injection sites recommended for vaccination.

In infants and children under two years of age, the deltoid muscle is usually not sufficiently developed - they should be injected into the vastus lateralis muscle (anterolateral thigh). If an injection into the deltoid muscle is not possible in adolescents and adults - e.g. B. because of local skin infections - these can also be vaccinated in the vastus lateralis muscle. This injection site is also recommended - regardless of age - for the application of adrenaline for the treatment of severe anaphylactic reactions.

Gluteus is "out"

In the past, intramuscular injections were preferably given into the gluteus maximus muscle. The advantage of this injection site when applying medication is that more than 2 ml injection volume can be applied. However, this injection site has not been recommended for vaccinations for several years for several reasons:

If the injection site is not chosen correctly, the sciatic nerve can be damaged. In addition to neurological deficits, this can result in persistent burning pain. In children, injury to this nerve can lead to stunted growth and foot deformities. Little known is the injection damage to the superior gluteus nerve, which causes the Mm. gluteus medius, gluteus minimus and tensor fasciae latae are supplied. Damage to the (purely motor) nerves is not accompanied by pain or sensitivity disorders. The muscle atrophy that occurs later is covered by a mostly thick layer of fatty tissue. Therefore, the cause of the resulting gait disturbance (waddling gait; Duchenne limping) is often misunderstood. In principle, nerve damage is also possible with injections in the area of ​​the upper arm and thigh, but the risk is significantly lower than in the area of ​​the buttocks.

In addition, the subcutaneous fat layer in the buttocks area of ​​many people is so strong that the injection does not end up in the muscles, but in the fatty tissue.

Specialist in urology - andrology
Specialist in internal medicine - travel medicine (DTG), aviation medical expert
Alexianer Krefeld GmbH, 47918 Krefeld

Conflicts of Interest: Dr. Leischker has received honoraria / travel support from Pfizer, Novartis, and Sanofi-Pasteur-MSD. He is a lecturer and member of the Academy of the Center for Travel Medicine (CRM) Düsseldorf