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Journal of Experimental and Integrative Medicine
DOI: 10.5455/jeim.220514.rw.009
www.jeim.org
J Exp Integr Med ● Jul-Sep 2014 ● Vol 4 ● Issue 3 171
INTRODUCTION
The world changes and developments in almost all areas,
particularly in the health care filed, are observed. When health is
impaired as a result of acute or chronic disease, drug application
is one of the most frequent used methods of treatment. In
addition, this kind of application is one of the most important
responsibilities of health personnel. Drug applications require
a comprehensive set of knowledge and skill. Evidence-based
developments in this area should be monitored carefully and
should be implemented [1,2].
Health personnel working in centers offering health care services
are responsible for the safety of the drug administered [2].
Drugs are applied in a variety of ways such as oral, topical
and parenteral [2,3]. Intramuscular injection is one of the
parenteral drug administration sites. This injection method is
used to deliver drugs to a large muscle mass. Gluteus maximus,
gluteus medius, gluteus minimus, rectus femoris, vastus
lateralis, and the deltoid and triceps muscles are commonly
used for intramuscular injection [4,5]. Muscles are supplied
by more veins than the subcutaneous tissues. Therefore, after
intramuscular injection, drug absorption is faster than in the
subcutaneous tissues. However, there are many risks associated
with intramuscular injections. In order to reduce these risks, the
anatomical structure of the treated area should be well known,
and the region selection must be very well [2-4,6-9].
The dorsogluteal (DG) region is commonly used for
intramuscular injections [2-4,6,7,10]. Another injection site of
the gluteal are the ventrogluteal (VG) region. This review was
organized with the aim to compare the reasons for the preference
of DG and VG regions and to explain the basis of evidence.
Articles related to the selection of injection site, to position
the patient and complications were reviewed and assessed. The
reasons for preference of DG and VG regions were compared.
SELECTION OF INJECTION REGION
The properties of the drug to be administered, the patient’s
age and the patient’s body measurements should be taken
into consideration for determining the intramuscular
Comparing applications of
intramuscular injections to dorsogluteal
or ventrogluteal regions
Erol Kilic1, Rivahi Kalay2, Cenk Kilic3
Mini Review
1Department of
Painting, Faculty of
Fine Arts, Akdeniz
University, Antalya,
Turkey, 2Department
of Biochemistry, Konya
Military Hospital, Konya,
Turkey, 3Department
of Anatomy, Faculty
of Medicine, Gulhane
Military Medical
Academy, Ankara, Turkey
Address for correspondence:
Address for correspondence:
Cenk Kilic, Gulhane
Askeri Tip Akademisi,
Anatomi Anabilim Dali,
06010 Ankara, Turkey.
Phone: +903123043510,
E-mail: ckilicmd@yahoo.com
Received:
Received: March 16, 2014
Accepted:
Accepted: May 22, 2014
Published:
Published: August 27, 2014
ABSTRACT
Intramuscular injection is a method used for drug delivery to large muscle mass. Muscles are supplied by
more veins than the subcutaneous tissues. Therefore, after intramuscular injection, drug absorption is faster
than in subcutaneous tissues. However, there are many risks associated with intramuscular injection. In order
to reduce these risks, the anatomical structure of the treated area should be well known, and the region
selection must be very well. The dorsogluteal (DG) region is commonly used for intramuscular injections.
This area is close to blood vessels and nerves. Furthermore, the subcutaneous tissue of this region is thicker
than the subcutaneous tissue of the other regions. For these reasons, it is the most dangerous region. The
majority of health personnel accept that DG region is the most reliable for intramuscular injections. However,
intramuscular injections to the ventrogluteal (VG) region have advantages in many ways. The VG region has
been recognized as a primary intramuscular injection region. It was reported that a lot of health staff is not
aware of the advantages of VG region. This review was organized with the aim to compare reasons for the
preference of DG and VG regions and to explain the basis of evidence. Articles-related to selection of injection
site, patient position and complications were reviewed and assessed. The reasons for preference of DG and VG
regions were compared. Since intramuscular injection an important duty of medical personnel, it is expected
that this review will be useful to update their knowledge on this issue.
KEY WORDS: Dorsogluteal region, injection, intramuscular, ventrogluteal region
Kilic, et al.: Comparing intramuscular injections
172 J Exp Integr Med ● Jul-Sep 2014 ● Vol 4 ● Issue 3
injection technique which will be applied to the patient [11].
Intramuscular injections made in the gluteal region are generally
implemented in DG and VG regions.
Although VG region is defined as the safest region [12], it was
reported that the majority of nurses (81.5%) chose the DG
region [13-15]. The main reasons for not to prefer the VG
region are; (1) the small anatomical structure of the region,
(2) the inability to identify this region, and (3) fear that the
patients may be damaged since this region is falsely believed
be not safe [16-18].
The most important problem related to the injection of the
gluteal region is concerned about complications. The thought
that gluteal region is not safe is depending on the experiences of
DG region injections. However, this thought has been shown to
be not correct for VG region [12,18-20]. It was stated that gluteal
injection causes less local side-effects than thigh injection [21-24].
Even in babies and small children, the VG region was shown to be
a suitable site for intramuscular injections [18]. In obese patients,
it was stated that a longer needle is required for VG intramuscular
injections to avoid side effects of the drug and for delivering the
drug intramuscularly [25].
Preference of VG intramuscular injections depends mainly
on the ability for making the injection in the supine, prone
and lateral positions which are much comfortable for the
patient [6,12,16]. VG region is also the most reliable region for
injection practices; the main reasons are: (1) the absence of
nerves and blood vessels in this region, (2) being away from bony
prominences, and (3) low possibility of falsely subcutaneous
injection [26].
PATIENT POSITIONING AND IDENTIFYING THE
INJECTION REGION
The determination of VG region is a little harder in the prone
position. However, probability of injections into the wrong area
is very low during VG intramuscular injection, because, unlike
the DG region, the VG region is determined by palpation
of the bony structures. On the other hand, the positional
displacement of the target region may occur during DG
intramuscular injection; this problem does not occur during
VG injections [11].
VG region can easily be determined by palpating the bony
structures, and its boundaries are well defined, since bone spurs
can be felt by hand without difficulty [6,16]. During palpation,
left hand and right hand are used on right hip and left hip for
identifying the injection region, respectively. The lower part of
the palm of the hand is placed on the greater trochanter, the
index finger is placed on the anterior superior iliac spine, the
middle finger is placed on the iliac crest, and the thumb shows
the groin. Injection is applied within the triangle formed by
the index finger, the middle finger and iliac crest [Figure 1].
During DG intramuscular injection, patient’s feet should be
turned inward, providing that the toes of face each other. The
DG region is above an imaginary line between the greater
trochanter and the posterior superior iliac crest. The injection
should be made laterally and superior to this imaginary line
while lying in the full prone position. However, in practice,
patients often can be positioned to half-side position instead of
full prone. In this case, the imaginary line is displaced upward.
Therefore, the injection is made into the gluteus medius
which is the target muscle of VG region instead of the gluteus
maximus [3]. Thus, the injection site should be determined
carefully in DG region. Because DG region is close to the sciatic
nerve and gluteal artery [2-4,6,7,10,11,27-32], paralysis as a
result of nerve damage and hematoma as a result of vascular
injury may occur in cases of careless determining the injection
site [33]. One of the most important complications as a result
of intramuscular injections is damage to the sciatic nerve, which
is particularly arising during DG injections [11,34].
PREFERING DG OR VG REGIONS?
Until recently, it was reported that the commonly used
intramuscular injection sites are DG, VG, laterofemoral and
deltoid regions [35-38]. It was expressed that the sciatic nerve
injuries often develop due to DG injections [2,6,7,36,39]. The
location of the sciatic nerve varies from individually; therefore
the risk for being injured exists anytime with DG injections [2].
Since imaginary lines are used for identifying the DG region,
easily mistakes can be made during determining the injection
region. Furthermore, the subcutaneous tissue of this region
is thicker than the subcutaneous tissue of other parts. For
these reasons, the DG region seems to be the most dangerous
intramuscular injection site [11] [Figure 2].
It was noted that the nurses use the most commonly the DG
region for intramuscular injections [15,40]. The majority
of health personnel accept that the DG region is the most
reliable site for intramuscular injection and that they are not
aware of the advantages of the VG region [16,17]. However,
intramuscular injections at the VG region have advantages in
many ways, and thus, the VG region has been recognized as a
primary intramuscular injection region [11,12].
Figure 1: Identifying the ventrogluteal injection region
Kilic, et al.: Comparing intramuscular injections
J Exp Integr Med ● Jul-Sep 2014 ● Vol 4 ● Issue 3 173
The VG region is a region that can be safely used instead of the
DG region for intramuscular injections [28]. It was reported
that VG intramuscular injections can be used safely in normal
and slightly overweight individuals. The study was conducted in
order to investigate the suitability for the VG injection region.
As a result, the reliability of the method was determined in all
of the individuals with body mass index (BMI) between 18.5
and 29.9. In addition, the method was found to be unreliable
in 15% of the individuals with BMI value of 30-40 and all of the
individuals with BMI above 40 [41].
Gluteus medius and gluteus minimus muscles are located
in the VG region [30,41]. The muscle tissue of VG region
is thicker than the muscle tissue of the DG region. The
subcutaneous tissue of VG region is thinner than the
subcutaneous tissue of the DG region. This condition reduces
the possibility of accidental injections into the subcutaneous
tissue [6,11,16,28,40,42]. There are topographically no large
nerves and blood vessels in the VG region. The region is being
innervated by small nerves and supplied by rami of the blood
vessels. This situation prevents possible injuries and reduces
pain [6,11,16,28,34,40].
Many complications were reported for intramuscular
injections at the DG region. Following VG injection, no report
regarding local complications resulting from the injection
technique was found [3,12,30]. A reported complication
with VG injection is muscle paralysis of the tensor fascia
lata; however, this complication is more likely to see in older
individuals with loss of muscle mass or in individuals who are
bedridden for a long time [6].
The determination of the VG region is a little harder in the
prone position. However, the probability of injections into
the wrong area is very low during VG intramuscular injection.
Additionally, the positional displacement of the target region
may occur during DG intramuscular injection; this problem
does not occur during VG injections [11].
Taken together, the reasons for the preference of the VG
region in case of intramuscular injections can be summarized
as follows; (1) minimal risk to damage the sciatic nerve,
(2) high reliability due to palpation of bone structures, (3)
implementation possibilities in more positions including supine,
prone and lateral position, (4) thicker gluteal muscles, (5) and
thinner subcutaneous adipose tissue [6,11,12,16].
CONCLUDING REMARKS
Intramuscular injection is often used by health professionals.
This injection is one of the routes of parenteral drug
administration. The sciatic nerve injury associated with
intramuscular injection causes many negative consequences
in terms of health staff and patients. Available evidence
indicates that DG region should be avoided for intramuscular
injections. The VG region is the safest intramuscular injection
site for several reasons, and thus, it is also the first choice site of
intramuscular injections. However, in practice, the DG region
is already used most frequently. This fact indicates that the
advantages of the VG region is not known or understood by the
majority of health personnel.
It is reported that the healthcare personnel did not receive
any other training after basic teaching of injection techniques.
They use many different methods [43]. They usually do not
use techniques that reduce pain and tissue damage [15]. Since
intramuscular injections are one of the most implemented
duties of medical personnel, their knowledge regarding
intramuscular injection needs to be updated.
The service training programs should be prepared about
preventing injection-related nerve injuries and update
knowledge of medical personnel on this subject. Although some
developments in theoretical knowledge about intramuscular
injections exist [4,7,41,44], avoidable complications still occur
in many countries. Therefore, reconsidering the intramuscular
injection subject in the curriculum of training of health personnel
seem to be of particular importance. During the training of
health personnel in the period before and after graduation, the
reasons for preference of the VG region should be explained, and
identification of the injection region should be shown in practice.
As final consideration, we recommend that more experimental
and clinical studies should be made on DG and VG intramuscular
injections. In addition, the use of terminology as “DG” and
“VG” regions is confusing; for future researches, we suggest
using “dorsomedial” and “dorsolateral” regions instead.
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