Australian Government Department of Health and Ageing Immunisation HandbookAustralian Government Department of Health and Ageing crest. Link to the Immunise Australia Program homepage.

1.4 Administration of vaccines

1.4.8 Identifying the injection site

Please note: due to continuous updates being made to the Immunisation Handbook, the page number on the electronic version will not always match the hard copy version.


The choice of injection site depends upon the age of the person, and is discussed in Section 1.4.6.

The anterolateral thigh (vastus lateralis)

  • The infant’s nappy must be undone to ensure the injection site is completely exposed and the anatomical markers easily identified.
  • Position the leg so that the hip and knee are flexed and the vastus lateralis is relaxed (see Figure 1.4.6).
  • The upper anatomical marker is the midpoint between the anterior superior iliac spine and the pubic tubercle, and the lower marker is the upper part of the patella.
  • Draw an imaginary line between the 2 markers down the front of the thigh. The correct site for IM vaccination is lateral to the midpoint of this line, in the outer (anterolateral) aspect (see Figures 1.4.5 and 1.4.6).
  • Do not inject into the anterior aspect of the thigh where neurovascular structures can be damaged.

Figure 1.4.5: Diagram of the muscles of the thigh showing the anatomical markers to identify the recommended (vastus lateralis) injection site (X)


Diagram of the muscles of the thigh showing the anatomical markers to identify the recommended (vastus lateralis) injection site (X)

Figure 1.4.6: Photograph of the thigh showing the recommended (vastus lateralis) injection site (X)


Photograph of the thigh showing the recommended (vastus lateralis) injection site (X)

Photo courtesy Lloyd Ellis, RCH, VIC


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The ventrogluteal area


NB. This area should not be confused with the dorsogluteal area (buttock).

The ventrogluteal site provides an alternative site for administering vaccines to a child of any age, especially when multiple injections at the same visit are required. The ventrogluteal area is relatively free of major nerves and blood vessels, and the area provides the greatest thickness of gluteal muscle.25,26 There is a relatively consistent thinness of subcutaneous tissue over the injection site.26,27
  • The child’s nappy must be undone to ensure the injection site is completely exposed and the anatomical markers easily identified by sight and palpation. Anatomical markers are the anterior superior iliac spine (ASIS), the greater trochanter of the femur and the iliac crest (see Figure 1.4.7).
  • Place the child in a prone position (face-down) on parent/carer’s lap or on the clinic table/bed with arms tucked against the child’s chest. Allow the child’s legs to dangle towards the floor (see Figure 1.4.8).
  • The knee and hip should be turned inwards to encourage muscle relaxation at the injection site.
  • The injection site should be that which is closest to the immunisation service provider.
  • Place the palm over the greater trochanter (the uppermost bony prominence of the thigh bone) with the thumb pointing towards the umbilicus. The index finger points to the anterior superior iliac spine, and the middle finger is spread so that it aims at the iliac crest, thus creating a ‘V’ outlining the ventrogluteal triangular area. The injection site is at the centre of this area (see Figures 1.4.7 and 1.4.8).

Figure 1.4.7: Diagram showing the anatomical markers to identify the ventrogluteal injection site (X) (ASIS = anterior superior iliac spine)


Diagram showing the anatomical markers to identify the ventrogluteal injection site (X) (ASIS = anterior superior iliac spine)

Figure 1.4.8: Photograph with infant prone across carer’s lap, showing markers to identify the ventrogluteal injection site (X)


Photograph with infant prone across carer’s lap, showing markers to identify the ventrogluteal injection site (X)

Photo courtesy Dr Joanne Molloy, VIC


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The deltoid area

It is essential to expose the arm completely from the top of the shoulder to the elbow when locating the deltoid site (see Figure 1.4.9). Roll up the sleeve or remove the shirt if needed.
  • The injection site is halfway between the shoulder tip (acromion) and the muscle insertion at the middle of the humerus (deltoid tuberosity).
  • Draw an imaginary, inverted triangle below the shoulder tip, using the identified anatomical markers.
  • The deltoid site for injection is the middle of the muscle (triangle) (see Figure 1.4.9).

Figure 1.4.9: Diagram showing the anatomical markers to identify the deltoid injection site


Diagram showing the anatomical markers to identify the deltoid injection site

Subcutaneous injection sites

Subcutaneous injections should be administered either over the deltoid muscle or over the anterolateral thigh. There are no data to demonstrate any difference
in technique between administration of a SC injection and a deep SC injection. Figure 1.4.10 demonstrates the recommended technique for any SC injection.

Figure 1.4.10: A subcutaneous injection into the deltoid area of the upper arm using a 25 gauge, 16 mm needle, inserted at a 45° angle


A subcutaneous injection into the deltoid area of the upper arm using a 25 gauge, 16 mm needle, inserted at a 45° angle

Photo courtesy Ann Kempe, MCRI, VIC



References


25. Zelman S. Notes on techniques of intramuscular injection. The avoidance of needless pain and morbidity. American Journal of the Medical Sciences 1961;241:563-74.

26. Greenway K. Using the ventrologluteal site for intramuscular injection. Nursing Standard 2004;18:39-42.

27. Michaels L, Poole RW. Injection granuloma of the buttock. Canadian Medical Association Journal 1970;102:626-8.

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