Skip to main content
NCBI home page
Nursing Open logoLink to Nursing Open
. 2023 Jul 14;10(9):5975–5988. doi: 10.1002/nop2.1902

Adverse effects of dorsogluteal intramuscular injection versus ventrogluteal intramuscular injection: A systematic review and meta‐analysis

María Teresa Roldán‐Chicano 1,2,✉, Javier Rodríguez‐Tello 1, Raquel Cebrián‐López 1, James Richard Moore 3, María del Mar García‐López 4
PMCID: PMC10415997  PMID: 37452553

Abstract

Aims

To determine adverse effects of ventrogluteal intramuscular injections versus dorsogluteal intramuscular injections.

Design

A systematic review and meta‐analysis.

Methods

MEDLINE, EMBASE, CINHAL, CENTRAL, LILACS(BVS), BDENF (BVS), WoS, IRCTP(WHO), ClinicalsTrials.gov and PROSPERO databases were searched with no restriction on year or language. Preferred Reporting items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were followed.

Results

A total of 1429 participants from 17 studies were included. The meta‐analysis found that ventrogluteal injection site had significant relation to lower pain in 9 studies (SMD = −0.63, 95% CI = −0.87, −0.39), bleeding in 4 studies (SMD = −3.46, 95% CI = −6.07, –0.86) and hematoma in 2 studies; after 48 h (SMD = −0.25, 95% CI = −0.39, −0.11), and after 72 h (SMD = −0.16, 95% CI = −0.26, –0.06), if it was compared with dorsogluteal site injection. No differences were found when comparing the possibility of intramuscular injections given into de subcutaneous tissue. In three studies, ventrogluteal site did not significantly reduce the risk of subcutaneous injection (OR 0,62, 95% CI = 0.16, 2.41).

Keywords: adverse effects, buttocks, dorsogluteal, injections, intramuscular, injections, intramuscular/adverse effects*, injections, intramuscular/methods*, injections, subcutaneous, nursing, systematic review, ventrogluteal

1. INTRODUCTION

Intramuscular injection deposits medication deep into muscle tissue, this route of administration provides rapid systemic action and absorption (Lippincott Williams & Wilkins, 2009). Ventrogluteal and dorsogluteal are two anatomical sites for routine intramuscular gluteal injections in adults. Ventrogluteal site (VS) is located at the hip in an inverted triangle formed by the iliac crest, the anterior superior iliac spine, and the greater trochanter of the femur, where we find the medius and minimus gluteus muscle. The dorsogluteal site (DS) is located in the superior lateral area of the maximus and medius gluteal muscles (Small, 2004).

Adverse effects of intramuscular injections have been recognised since the nineteenth century. ‘Sciatic neuritis due to injection’ was first reported in 1882 (Wexburg, 1935, as cited in, Jung Kim & Hyun Park 2014), but it is not until the 1920s that medical literature regularly describes possible injuries associated with injections, leading to authors advising against the dorsogluteal site (Castellanos, 1977). In this context, the Swiss anatomist (Von Hochstetter, 1954) proposes to avoid injuries to the sciatic nerve and perineuronal area by using the ventrogluteal injection site. Subsequent medical literature has provide evidence of the safety and efficacy of this site, highlighting its distance from the sciatic nerve (Yalcin et al., 2015), relatively low number of veins present (except some branches of superior gluteal artery or vein; Nakajima et al., 2020) and the reduced thickness of the subcutaneous tissue in comparison with the dorsogluteal site (Arslan & Özden, 2018; Elgellaie et al., 2018; Larkin et al., 2018; Nisbet, 2006). However, some studies present ventrogluteal site as an area that is not exempt from risks (Müller‐Vahl, 1985; Obach et al., 1983; Wu et al., 2020). The safety of the ventrogluteal site has also generated doubts.

Varying and fragmented information exists about which is the most suitable gluteal injection site in adults.

2. BACKGROUND

Dorsogluteal site remains the most widely used in clinical settings, whereas VS is hardly used, which makes difficult to assess the real risks of this site. Research has found the reasoning behind the reluctance of health care professionals to use VS is based on: the belief that it is a more painful site and there is a higher risk of reaching bone tissue, or perception of self‐injury using the V‐finger method (Arslan & Özden, 2018; Brown et al., 2015). Meneses & Marques argued in 2007 that the V method does not always maintain a proportional relationship between the size of the professional's hand and the patient's injection site, which could lead to inaccurate injection. There is a large amount of literature that discusses the causes behind the limited use of the VS, but the most influential seem to be the insufficient knowledge and training and the consequential lack of confidence and familiarity with its anatomical landmarks (Su & Bekmezci, 2020).

Some authors state that the problem is not that there is a failure in transferring the research results to clinical settings, but rather a lack of strong empirical evidence due to the shortage of rigorous designs, and studies that allow the proportional evaluation of adverse effects in both sites of injection (Brown et al., 2015; Gillespie & Toner, 2013).

3. THE REVIEW

3.1. Aims

This systematic review aimed to evaluate and summarise all the available evidence comparing VS and DS to provide recommendations for selection of intramuscular gluteal site injections. The aim was to determine the adverse effects in VS and DS.

3.2. Design

This systematic review and meta‐analysis was developed according to the PRISMA guideline (Page et al., 2021). A PICO (Population, Intervention, Comparator, Outcome) framework was used to conceptualise the search strategy. The protocol of this review was registered with the International Prospective Register for Systematic Reviews (PROSPERO registration number: CRD42020152074).

3.3. Search methods

Scoping searches were initially carried out to refine search strategy. Thereafter, a literature search was conducted until May 2021 in MEDLINE, EMBASE, CINHAL, CENTRAL, LILACS(BVS), BDENF (BVS), WoS, IRCTP(WHO), ClinicalsTrials.gov and PROSPERO databases. Google Scholar was used as a citation index (articles that cited studies selected in databases were reviewed, this process was an important contribution of grey literature to this systematic review; Paez, 2017). There was no restriction of the languages.

3.4. Inclusion criteria

This systematic review considered any empirical design comparing VS intramuscular injection and DS intramuscular injection in adult population ≥ 18 years: controlled studies (randomised controlled trials, RCT), quasi experimental studies, prospective and retrospective cohort studies, case–control studies and any controlled observational or cross‐sectional studies.

3.5. Search outcomes

The outcomes of interest were those related to adverse effects, potential adverse effects or altered effectiveness. Vascular injury (clinical symptoms), soft tissue infection or injury (incidence/number of clinical symptoms of infection or injury), level of pain (any validated scale), nerve injury (symptoms, electromyography, imaging methods, nerve conduction studies), bone injury (symptoms, imaging methods studies) and effectiveness (biodisponibility, plasma concentration, imaging diagnostic technique studies). Potential adverse effects: potential nerve injury (distance from real or theoretical site of injection to sciatic nerve), potential vascular injury (distance from real or theoretical site injection to vascular bundles), potential bone injury (distance from real or theoretical site injection to bone) and potential non intramuscular injection (comparing subcutaneous adipose tissue thickness and needle length).

3.6. Screening

Abstract screening was undertaken independently by two reviewers (M.R. and J.R.) using the Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org. Those articles that were considered eligible were retrieved in full and independently assessed according to the eligibility criteria by the same two reviewers. Disagreements were resolved by discussion.

3.7. Quality appraisal

Observational and cross‐sectional studies were assessed using an adapted form of the Newcastle‐Ottawa scale for cross sectional studies (Moskalewicz & Oremus, 2020). The Cochrane Collaboration's ‘Risk of Bias’ tool (Higgins & Green, 2011)  was used for RCTs and Joanna Briggs Institute Reviewers Manual (The Joanna Briggs Institute, 2020) for quasi experimental studies. Each article was evaluated independently by two authors, inconsistencies were resolved by way of discussion.

3.8. Data abstraction

Data were extracted by one reviewer (M.R.) and revised by a second reviewer (J.R.). The following data were extracted: study characteristics (primary author, year, country, aims, design, inclusion and exclusion criteria and sample size), participation characteristics (mean/SD age, gender, body mass index), intervention (method to locate site of injection, substance and volume injected and size of needle) and outcome (outcome measure from each group, number of participants from each group).

3.9. Data synthesis

Comparability of studies was based on terms of intervention and outcome measures. When two or more comparable studies were identified, the results were pooled in a meta‐analysis. Review Manager (RevMan) Version 5.3 (Rev Man; Cochrane Collaboration, 2014) software was used for meta‐analysis and forest plots. Odds ratios (ORs) with 95% confidence interval (CI) were used for dichotomous variables, and mean differences and standardised mean difference (SMD) with the corresponding 95% (CI) were calculated as the effect size for estimating numerical variables.

The heterogeneity in the included research results was analysed by chi‐square, χ2 test (α = 0.1) and I 2 statics. A random effects model was used when significant heterogeneity existed, p < 0.1 and I 2 > 50%, in case of not significant heterogeneity a fixed effects model was used. Subgroup analysis was performed, stratified either by gender, body mass index (BMI), drug type and additional injection methods (Z‐track and Air‐lock).

Publication bias detection was conducted through symmetry of funnel plots that were generated by RevMan 5.2. Potential publication bias was considered if the visual inspection of the funnel plots revealed substantial asymmetry. Sensitivity analysis was performed by calculating the pooled effect size after removing studies one at a time to evaluate whether the result would be influenced by a single study.

4. RESULTS

Database searches identified 250 potential studies, and citation searching 12. Duplicate and ineligible studies were removed, and two reviewers screened 166 articles independently. One hundred and fifty‐seven records were excluded. Nine studies identified from databases, and 12 studies identified from citation searches were independently assessed for eligibility, by the same two independent reviewers. Any disagreement was resolved by discussion. Finally, 17 studies were included in the quantitative and qualitative analysis. The PRISMA 2020 flow diagram (Page et al., 2021) in Figure 1 shows the study selection process.

FIGURE 1.

FIGURE 1

Open in a new tab

PRISMA 2020 flow diagram.

4.1. Systematic search results

Seven quasi‐experimental studies, and 2 RCT evaluated the effects of the two injection techniques on pain and/or bleeding and/or bruising. Seven cross sectional studies and 1 observational study focused on the measurement of the thickness of subcutaneous tissue and muscles in DS and VS, reporting data on the precision of the injection (theoretical injection site in muscular or subcutaneous tissue). Table 1 summarises characteristics of the included studies. The sample size of the studies ranged from n = 25 to 190. The total sample size of the included studies was 1429 (47.2% men and 52.8% women). Most of the studies identified DS using quadrant method and VS using the V method. In quasi‐experimental and experimental studies most reported the use of 21G needle‐38 mm (1.5 inch)/30 mm (1 inch), only one study reported the use of a 25 mm needle. Four studies reported the use of diclofenac sodium, 3 used antibiotics and 1 vitamin B‐12; the volume administered ranged from 1 to 3 mL. One study used Z‐track technique, 2 Air‐lock method and 3 Air‐lock and Z‐track technique together. In the studies that measured SAT (subcutaneous adipose tissue), one study conducted CT‐scans and seven ultrasound procedures. Out of all possible outcomes, the only ones we were able to report are pain, bleeding, hematoma and SAT that indicates, potentially, an unsuccessful intramuscular injection. All studies used VAS (0–10) for pain assessment, Opsite‐Flexigrad or a gauze for bleeding (mm) and hematoma area (cm2).

TABLE 1.

Characteristics of included studies.

References Design Sample size groups Injection protocol Outcome Outcome tool
Apaydin (2018) Quasi‐experimental 102 (VS) 102 (DS) 21G needle. Drug volume: 1 mL. Vitamin B12. Z‐track. DS quadrant method. VS V method Bleeding. Pain. Hematoma 48 and 72 h post injection Opsite‐Flexigrad (cm)VAS (0–10) Hematoma area (mm)
Choi et al. (2010) Cross sectional 190 (VS) 190(DS) DS quadrant method. VS V method SAT Ultrasound System, 7.5 MHz linear‐array transducer
Elgellaie et al. (2018) Cross sectional 60 (VS) 60 (DS) DS quadrant method. VS V and G method Muscle thickness and SAT Doppler Ultrasound System, using a linear (L7–42; 5–12 MHz) or convex array transducer (C3–44; 2–5 MHz)
Güneş et al. (2008) Cross sectional 114(VS) 114 (DS) VS V method. DS, diagonal line joining superior iliac spine with the trochanter Muscle thickness and SAT Ultrasound System, 7.5 MHz linear‐array transducer
Güneş et al. (2013) Quasi‐experimental 70 (VS) 70 (DS) 21G needle. Drug volume: 3 mL. Diclofenac sodium. Air lock. DS quadrant method. VS V method Pain VAS (0–10)
Isseven et al. (2020) Quasi‐experimental 60 (VS) 60 (DS) Cephalosporin. Air lock and Z‐track technique. DS quadrant method. VS V method Pain VAS (0–10)
Kemaloğlu (2013) Quasi‐experimental 100 (VS) 100 (DS) 21G needle. Drug volume: 3 mL. Air lock and Z track. Diclofenac sodium. DS quadrant method. VS V method Bleeding. Pain. Hematoma 48 and 72 h post injection. Echimosis 48 and 72 h ours post injection Opsite‐Flexigrad (cm)VAS (0–10) Hematoma area (mm)
Larkin et al. (2018) Cross sectional 145 (VS) 145 (DS) DS quadrant method. VS V method Muscle thickness and SAT Doppler Ultrasound System, (mm)
Masuda et al. (2016) Cross sectional 39 (VS) 39 (DS) DS quadrant method. VS V method Muscle thickness and SAT Doppler Ultrasound System, using 7.5 MHz linear and convex array transducer and ultrasonograph diagnostic system, (mm)
Moharreri et al. (2007) Quasi‐experimental 67 (VS) 67 (DS) DS quadrant method. VS V method Pain and bleeding VAS (0–10). Sterile gauze pad on the injection site and measure the diameter of the blood stain on the gauze with a millimetre ruler (mm)
Nisbet (2006) Observational 100 (VS) 100 (DS) DS quadrant method. VS V method SAT Computed tomography scans (mm)
Oçal (2012) Quasi‐experimental 60 (VS) 60 (DS) 21G needle. Drug volume: 3 mL. Air lock and Z track technique. Diclofenac sodium. DS quadrant method. VS V method Bleeding. Pain. Hematoma 48 and 72 h post injection Opsite‐Flexigrad (cm)VAS (0–10) Presence of hematoma
Oliveira et al. (2015) RCT 31 (VS) 27 (DS) Needle 25 × 8.0 mm weight ≤ 70 kg and 30 × 8.0 mm in weight >70 Kg, bencilpenicilina benzatina G, DS quadrant method. VS V method Pain VAS (0–10)
Tuğrul and Khorshıd (2014) Quasi‐experimental 60 (VS) 60 (DS) 21G. Drug volume: 2 mL. Penicillin G. Pain VAS (0–10)
Yalcin et al. (2015) Cross sectional 25 (VS) 25 (DS) DS marked by experienced nurse, VS under the iliac crest Muscle thickness and SAT Ultrasonography and linear array (7–12 MHz)
Yılmaz et al. (2016) RCT 30 (VS) 30 (DS) 21G. Drug volume: 2 mL. Diclofenac sodium. Air‐lock. DS quadrant method. VS V method Pain VAS (0–10)
Zaybak et al. (2007) Cross sectional 119 (VS) 119 (DS) DS upper a line between posterior superior iliac spine and greater trochanter. VS V and G method SAT Ultrasound System, 7.5 MHz linear‐array transducer
Open in a new tab

Abbreviations: APTT, activated partial thromboplastin time; cm, centimetres; DS, Dorsogluteal; F, feminine; G, gauge; INR, international normalised ratio; kg, kilograms; MHz, mega hertz; ml, millilitres; M, masculine; RCT, randomised control trial; SAT, subcutaneous adipose tissue; VAS, visual analogic scale; VS, ventrogluteal.

4.2. Risk of bias assessment

Studies included in this review were of variable methodological quality. All observational and cross‐sectional studies were deficient in various aspects of the sample selection (representative, sample and non‐respondents), 100% of RCTs were not blinded experiments and 1 RCTs did not clearly state the method used for the allocation concealment. Quasi experimental studies had a low or medium risk of bias because any study reported data of multiple measures of outcome (for example pain pre and post injection), as shown in Tables 2, 3, 4.

TABLE 2.

Newcastle‐Ottawa scale (NOS) for the risk of bias adapted for cross‐sectional studies.

References Selection Comparability Exposure Total score
Representative of the sample Sample size Non‐respondents Ascertainment of the exposure Comparability of subjects in different outcome groups on the basis of design or analysis. Confounding factors controlled. Assessment of outcome Statical test
Larkin et al. (2018) ** ** ** * 7

Choi et al. (2010)

 ** ** ** * 7
Masuda et al. (2016) ** ** * 7

Elgellaie et al. (2018)

 ** ** ** * 7
Yalcin et al. (2015) ** * ** 5

Güneş et al. (2008)

 ** ** ** * 7
Zaybak et al. (2007) ** ** ** * 7
Nisbet (2006) ** * ** 5
Open in a new tab

Note: SCORES: 9–10 points (very good studies), 7–8 points (good studies), 5–6 points (satisfactory studies).

TABLE 3.

Risk of bias and quality assessment of quasi‐experimental (JBI Reviewers Manual, 2016).

References Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9
Moharreri et al. (2007) Y Y Y NA UC UC Y N UC
Apaydin (2018) Y Y Y NA UC UC Y Y Y
Tuğrul and Khorshıd (2014) Y Y Y NA UC Y Y Y Y
Isseven et al. (2020) Y Y Y NA UC Y Y Y Y
Kemaloğlu (2013) Y Y UC NA UC UC Y Y Y
Oçal et al. (2012) Y Y Y NA UC UC Y Y Y
Güneş et al. (2013) Y Y Y NA UC Y Y Y Y
Open in a new tab

Note: Q1. Is it clear in the study what is the ‘cause’ and what is the ‘effect’?; Q2. Were the participants included in any comparisons similar?; Q3. Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest?; Q4. Was there a control group?; Q5. Were there multiple measurements of the outcome in both pre‐ and post‐intervention/exposure?; Q6. Was the follow‐up complete, and if not, was the follow‐up adequately reported strategies to deal with the loss to follow‐up employed?; Q7. Were the outcomes of participants included in any comparisons measured in the same way?; Q8. Were outcomes measured in a reliable way?; Q9. Was appropriate statistical analysis used?

Abbreviations: N, no; NA, not applicable; Q, question; UC, unclear; Y, yes.

TABLE 4.

Risk of bias and quality assessment of RCTs. Cochrane Collaboration's Risk of Bias (Higgins & Green, 2011).

References Random sequence generation Allocation concealment Blinding of participant and personnel Blinding of outcome assessment Incomplete outcome data Selective reporting Other bias
Oliveira et al. (2015) Low Low High Unclear Low Unclear Low
Yılmaz et al. (2016) Low Unclear High Low Low Unclear Low
Open in a new tab

Abbreviations: High, high risk of bias; Low, low risk of bias; Unclear, unclear risk of bias.

4.3. Publication bias

No obvious publication bias was found according to the funnel plot (Figure 2‐Funnel plot quasi experimental and RCT studies). Funnel plot was not assessed for other part as there were few studies comparison available. The contribution of grey literature in this systematic review provided data not found within commercially published literature, reducing publication bias.

FIGURE 2.

FIGURE 2

Open in a new tab

Funnel plot, publication vias.

4.4. Thickness of subcutaneous tissue

In total, 5 of the 17 included studies evaluated the thickness of subcutaneous tissue (Elgellaie et al., 2018; Güneş et al., 2008; Larkin et al., 2018; Masuda et al., 2016; Nisbet, 2006). Combining thickness (mm) in both injection sites showed that VS was significantly thinner than DS (MD = −5.45, 95% CI = −9.65, −1.25) (Elgellaie et al., 2018; Güneş et al., 2008; Larkin et al., 2018; Masuda et al., 2016; Nisbet, 2006). A random effects model was adopted because heterogeneity existed across studies (p < 0.00001, I 2 = 92%), as shown in Figure 3. Subgroup meta‐analysis showed women had significantly lower SAT in VS than men (MD = −3.61, 95% CI = −6.29, −0.93), also a random effects model was used to combine data, again because of the existence of heterogeneity across studies (p < 0.0001, I 2 = 85%).

FIGURE 3.

FIGURE 3

Open in a new tab

Forest plot mean difference (MD) of subcutaneous adipose tissue.

Body Mass Index and gender subgroups were analysed, although it was only possible to combine data from 2 studies (Choi et al., 2010; Larkin et al., 2018). Meta‐analysis showed significant differences between subgroups (SMD = −0.63, 95% CI = −0.85, −0.41). Combined data was analysed using a fixed effects model because there was no significant heterogeneity between studies (p = 0.08, I 2 = 40%). VS had significantly lower SAT in men and women in normal weight (18.5–24.9) and overweight (25–29.9), but not in obese (>30).

Three studies (Larkin et al., 2018; Nisbet, 2006; Zaybak et al., 2007) reported data on the theoretical injection site (intramuscular injection or subcutaneous injection). In 364 participants up to 31% of VS injection resulted in a subcutaneous (37.4% in women and 18.2% in men), and 37% in dorsogluteal site (50% in women and 20.4% in men). One of the studies (Larkin et al., 2018) reported the outcome with a dichotomous variable (theoretical subcutaneous or intramuscular injection with a 21G needle‐38 mm needle) and the other two described cases in which the SAT was ˃33.1 mm (Zaybak et al., 2007) or ˃35 mm (Nisbet, 2006). With 21G needle‐38 mm (1.5 inch), approximately 5 mm does not penetrate the skin (Strohfus et al., 2021) so data of these studies was considered appropriate to discriminate theoretical subcutaneous injection when a 21G needle‐38 mm (1.5 inch) was used. A random effects model was adopted because there was evidence of significant between‐study heterogeneity (p < 0.0001, I 2 = 91%). Effect size in this meta‐analysis suggests that VS does not significantly reduce the risk of subcutaneous injection (OR 0,62, 95% CI = 0.16, 2.41).

The data could not be combined into BMI subgroups, so we approached this point using available data. The skin to muscle depth should not exceed 33.1 mm if using a 38 mm needle (Strohfus et al., 2021), so we analysed if a 21G needle‐38 mm (1.5 inch), could reach muscle, based on the mean and standard deviation measures skin to muscle provided in four studies: (Choi et al., 2010; Güneş et al., 2008; Larkin et al., 2018; Zaybak et al., 2007). We found homogeneity in outcomes of participants with BMI <25: the injection would be intramuscular in both VS and DS. In overweight and obese participants, results are dissimilar, as shown in Table 5.

TABLE 5.

Comparison of the injection depth in the ventrogluteal and dorsogluteal sites according to body mass index and gender.

Ventrogluteal site injection Dorsogluteal site injection
BMI References n Gender Mean ± SD STM TSI AM TSI AMD Mean ± SD STM TSI AM TSI AMD
Normal weight Choi et al. (2010) 50 Women 18.5 ± 4.8 IM i IM i 22.7 ± 5.8 IM i IM i
Men 10.4 ± 3.7 IM i IM i 13.1 ± 3.7 IM i IM i
Güneş et al. (2008) 56 Total (m + w) 18 ± 7.5 IM i IM i 19.9 ± 7.1 IM i IM i
Larkin et al. (2018) 75 Women 11.2 ± 5 IM i IM i 18.4 ± 5.9 IM i IM i
Men 7.6 ± 3.3 IM i IM i 12.7 ± 5.6 IM i IM i
Overweight Choi et al. (2010) 50 Women 23.6 ± 7.8 IM i IM i 30 ± 10.9 IM i SBC i
Men 17.3 ± 5.6 IM i IM i 19.1 ± 5.7 IM i IM i
Güneş et al. (2008) 35 Total (m + w) 28.7 ± 12.2 IM i SBC i 28.2 ± 11.9 IM i SBC i
Larkin et al. (2018) 47 Women 17.2 ± 6.1 IM i IM i 20 ± 7.8 IM i IM i
Men 10.4 ± 4 IM i IM i 14 ± 6.6 IM i IM i

Zaybak et al. (2007)

 20 Women 50.4 ± 1.37 SBC i SBC i 50.5 ± 0.92 SBC i SBC i
Men 31.2 ± 0.88 IM i IM i 27.6 ± 1.1 IM i IM i
Obese Choi et al. (2010) 50 Women 32.6 ± 10.5 IM i SBC i 37.4 ± 14 SBC i SBC i
Men 19.2 ± 6.3 IM i IM i 21 ± 8.2 IM i IM i
Güneş et al. (2008) 19 Total (m + f) 41.1 ± 14 SBC i SBC i 42.1 ± 2.8 SBC i SBC i
Larkin et al. (2018) 23 Women 28.1 ± 9.6 IM i SBC i 29.2 ± 11.1 IM i SBC i
Men 17.5 ± 10.4 IM i IM i 24.4 ± 11.2 IM i SBC i
Zaybak et al. (2007) 66 Women 54.3 ± 1.09 SBC i SBC i 51.7 ± 1.2 SBC i SBC i
Men 37 ± 1.05 SBC i SBC i 30.7 ± 1 IM i IM i
Open in a new tab

Abbreviations: BMI, body mass index; IM i, intramuscular injection; m + f, men and female; SBC i, subcutaneous injection; SD, standard deviation; STM, skin‐to‐muscle; TSI AMD, theoretical subcutaneous tissue injection assuming maximum deviation; TSI AM, theoretical subcutaneous tissue Injection Assuming medium; TSI, theoretical subcutaneous tissue injection.

4.5. Muscle thickness

Three studies reported data about muscle thickness in VS and DS (Güneş et al., 2008; Larkin et al., 2018; Yalcin et al., 2015). No significant difference was found between the thickness of muscles in VS and DS (MD = −4.96, 95% CI = −13.35, 3.43), with evidence of high heterogeneity (p < 0.0001, I 2 = 97%).

4.6. Pain

Nine studies assessed pain at VS and DS; 7 quasi‐experimental studies (Apaydin, 2018; Güneş et al., 2013; Isseven et al., 2020; Kemaloğlu, 2013; Moharreri et al., 2007; Öçal, 2012; Tuğrul & Khorshıd, 2014) and 2 RCT (Oliveira et al., 2015; Yılmaz et al., 2016). To combine these nine studies a random effects model was adopted because heterogeneity existed across all (p < 0.0001, I 2 = 74%). In the case of VS, pain was significantly lower if compared with DS (SMD = −0.63, 95% CI = −0.87, −0.39; Figure 4).

FIGURE 4.

FIGURE 4

Open in a new tab

Forest plot standardised mean difference (MD) of pain.

Subgroup analysis of the nine studies showed that VS pain was significantly less with or without any additional method. Size effect increased when Air‐lock technique and Z‐track technique were used together (SMD = −0.95, 95% CI = −1.15, −0.75) and only with Z‐track method (SMD = −0.93, 95% CI = −1.22, −0.64). Ventrogluteal was still an advantageous site for pain reduction, even if the Air‐lock technique was used alone, or no technique was used, although in these cases the size effect was lower. A random effects model was used because of heterogeneity (p = 0.0001, I 2 = 73%), as shown in Figure 5.

FIGURE 5.

FIGURE 5

Open in a new tab

Forest plot, subgroup analysis of additional methods to reduce pain.

Advantage of VS disappeared in studies using antibiotics. Drug‐type subgroup analysis applied a random effects model (p = 0.0001, I 2 = 77%) and only showed a statistically significant pain reduction at the VS when administering drugs other than antibiotics (diclofenac sodium was injected in four studies, and vitamin B in 1). Antibiotics (SMD = −0.47, 95% CI = −1.01, 0.07) and other drugs (SMD = −0.73, 95% CI = −1.03, −0.42) are shown in Figure 6.

FIGURE 6.

FIGURE 6

Open in a new tab

Forest plot, subgroup analysis of drugs administrated on pain.

4.7. Bleeding

A total of four studies provided information for bleeding after the injection (Apaydin, 2018; Kemaloğlu, 2013; Moharreri et al., 2007; Öçal, 2012). There was a statistically significant reduction in bleeding in the VS if compared with DS (SMD = −3.46, 95% CI = −6.07–0.86), with evidence of heterogeneity across studies (p < 0.00001, I 2 = 99%), as shown in Figure 7.

FIGURE 7.

FIGURE 7

Open in a new tab

Forest plot standardised mean difference (MD) of bleeding.

4.8. Hematoma

Three studies provided data on the presence of hematoma at the two injection sites, however, in Öçal (2012) study was impossible to determinate hematoma diameter (mm), and only two studies could be combined (Apaydin, 2018; Kemaloğlu, 2013). Hematoma was measured at 48 and at 72 h. The scores were combined in a subgroup analysis using a fixed effects model because there was not significant heterogeneity between studies (p = 0.32, I 2 = 0.6%). VS is associated with a reduction of hematoma in both, after 48 and 72 h. The largest effect size was after 72 h hematoma (SMD = −0.16, 95% CI = −0.26, –0.06) if compared with 48 h hematoma (SMD = −0.25, 95% CI = −0.39, −0.11).

4.9. Sensitive analysis

To evaluate whether methodological quality of included studies influenced the results, two studies with the lower score in quality appraisal were removed, Nisbet (2006) and Yalcin et al. (2015). Direction of results was maintained but effect size was lower.

5. DISCUSSION

Some outcomes related to safety and accuracy of VS and DS intramuscular injection have not been studied clinically (bioavailability or clinical effects of medication on these two injection sites); however, using diagnostic techniques, CT‐scans, or ultrasound, it is possible to evaluate skin to muscle depth. Hypovascularity of SAT compared with muscle tissue could result in a reduction of bioavailability or slower uptake of medication (Strohfus et al., 2021).

Overall, we identified a significantly thinner SAT in VS; however, this difference was not enough to guarantee a lower risk of subcutaneous injection at the ventrogluteal site than at the dorsogluteal site. Strohfus combining data from 4 studies (Boyd et al., 2013; Chan et al., 2006; Larkin et al., 2018; Shah et al., 2014) obtained a DS theoretical SAT injection rate of 41.6% in women and 29.33% in men.

Correlation between SAT thickness in VS and DS and gender BMI is not always straightforward (Soliman et al., 2018). Some authors defend new approaches to discriminate the best injection site using algorithms that integrate anthropometric parameters, body shape and some anatomic references (Larkin et al., 2017, 2018). However, this categorization of patients requires a more careful assessment which can be difficult to carry out in certain clinical settings. In the case of individuals with normal weight and overweight men, a 21G needle‐38 mm (1.5 inch) could reach the muscle in VS and DS in most cases, but if the patient is obese and had a greater than 35 BMI, an ultrasound would be needed to determine the length of needle (Strohfus et al., 2021). These recommendations are in fact already proposed in some drug leaflets like common antipsychotic long‐acting IM injections (Soliman et al., 2018). In women who are obese (BMI 35 and over), the combined studies pointed to a 50 mm needle with the guidance of an ultrasound (Strohfus et al., 2021). In overweight women, to ensure an intramuscular injection in 100% of the cases a 50 mm needle should be used, however, only Larkin measurements are available to calculate that the length of this needle is safe and does not exceed the muscle. Larkin reported that muscle thickness in overweight women is 39 (10.2) mm in VS and 53.8 (9.3) mm in DS. This thickness together with that of the SAT, 17.2(6.1) mm in VS and 20 (7.8) mm could be safe at DS, but safety margin is remarkably close in VS. More evidence is needed to establish muscle depth in dorsogluteal and ventrogluteal injections.

Intramuscular injections given into the subcutaneous tissue can lead to a lower bioavailability of the administered drug, due to the lack of drainage in subcutaneous tissue. Other adverse effects related to injection into fat/subcutaneous tissue have also been reported such as irritation, pain, calcified granulomas and even abscess (layers of fat do not contain some cells to initiate the immune response, phagocytic or antigen‐presenting cells, so pathogens are associated with rapid rise in fat tissue; Razzouki et al., 2013).

Incidence of developing these complications could be 0.4% or higher (Razzouki et al., 2013). Cassiani and Rangel (1999) summarised the publications that reported this type of complications over a 27‐year period (1990–1997). Of 670, none of them occurred in VS, and at least 382 occurred in DS. Haramati et al. (1994), identified 160 calcified granulomas via CT‐scan: 152 were in the SAT and all caused after a DS injection. Razzouki et al. (2013), in a prospective analytic study over a period of 6 months, recorded 42 abscesses in the gluteal area that had been operated on, in his hospital, 39 due to intramuscular injections in DS. No studies were found that compared this type of injuries in VS and DS. The greater number of lesions in the DS could be due to the fact that this injection site is proportionally more common, but evidence that the DS area has a higher SAT, also could cause a higher probability of this type of injury in the dorsogluteal area.

Some authors comment that muscle thickness in the injection site is significant for drug emulsion (Arslan & Özden, 2018; Güneş et al., 2013; Masuda et al., 2016). Combining data from (Güneş et al., 2008; Larkin et al., 2018; Yalcin et al., 2015), we found that there was no statistically significant difference between the muscle thickness of VS and DS, as Coskun argue in his cadaveric study.

Probably, the most common complication related to injections is pain (Sahebkar et al., 2021). Penetration of the skin by the needle, mechanical and chemical effects of the drug and physical characteristics of the patient are non‐modifiable pain risk factors. However, some techniques can reduce pain (Ayinde et al., 2021; Şanlialp Zeyrek et al., 2019). Combining results from nine studies (Apaydin, 2018; Güneş et al., 2013; Isseven et al., 2020; Kemaloğlu, 2013; Moharreri et al., 2007; Öçal, 2012; Oliveira et al., 2015; Tuğrul & Khorshıd, 2014; Yılmaz et al., 2016), we found a significantly relation to lower pain in VS n (SMD = −0.63, 95% CI = −0.87, −0.39), as Şanlialp Zeyrek et al. (2019), reported in a previous systematic review.

Some of the analysed studies used the air lock or/and Z‐track techniques to reduce pain (Apaydin, 2018; Güneş et al., 2013; Isseven et al., 2020; Kemaloğlu, 2013; Öçal, 2012; Yılmaz et al., 2016). With or without these techniques, VS injection is less painful, and pain reduction is greater with the use of the air lock and Z‐track techniques together and with the Z‐track technique alone. This result is in line with two reviews (Ayinde et al., 2021; Şanlialp Zeyrek et al., 2019). When antibiotics, which are considered one of the most painful medications, are administered, the pain reduction is not significant using the VS.

The bleeding measured in this review is that which occurs after the withdrawal of the needle usually caused by injury of small vessels that may have been crossed during the injection procedure. Measurements were also made on participants in whom no coagulation problems were previously detected. The VS presented less bleeding and less bruising than the DS (Apaydin, 2018; Kemaloğlu, 2013; Moharreri et al., 2007; Öçal, 2012).

Undoubtedly, one of the main causes that calls into question the DS, primarily, is the possible injury to the sciatic nerve, caused directly from the needle itself or indirectly from the substance injected, which injures the epineural area (Jung Kim & Hyun Park, 2014).

Yalcin is the only author that calculated, in patients with a BMI < 22, the average distance of the two analysed injection sites to the sciatic nerve: 18 ± 3.5 for VS and 9 ± 2.3 cm for DS (Yalcin et al., 2015). Coskun measured the distance to superior gluteal artery and superior gluteal nerve, but in a cadaveric study, also obtaining a smaller distance towards neurovascular structures in DS (Coskun et al., 2016).

Some authors point out that the injuries to the sciatic nerve that result from the DS should be better measured (Jung Kim & Hyun Park, 2014; Mishra & Stringer, 2010). Many of these injuries are in children and not in adults (Mishra & Stringer, 2010) or caused by poor technique and being administered by inadequately trained or unqualified staff, mostly in undeveloped nations (Jung Kim & Hyun Park, 2014). However, sciatic nerve injuries also occur in the Western countries (Kim et al., 2004; Mishra & Stringer, 2010; Small, 2004) and by health professionals (Mishra & Stringer, 2010). Jung Kim and Hyun Park (2014) and Small (2004) point out that the overall incidence of nerve injection injuries is unknown, which may be because such injuries are already well known by most health care professionals and are considered unnecessary for publication, consequently some authors have resorted to legal documents to try to get to know the proper size of the problem (Mishra & Stringer, 2010; Small, 2004).

Serious injuries are not limited to the sciatic nerve, others have also been documented, such as Nicolau syndrome, necrosis, or fibrosis that triggers reduced movement (Cassiani & Rangel, 1999; Kaya et al., 2014). Most of the studies that report this type of serious complications, however, refer only to gluteal injection, without specifying whether they have been administered in VS or DS, which makes it impossible to include them as evidence in this review.

A detailed analysis of the literature did not reflect a unanimous view in dorso vs ventro debate. Some authors argument that when accurately identified, an injection into the DS carries no greater risk (Larkin et al., 2018; Sahebkar et al., 2021). The safety of the ventrogluteal site has also generated doubts. Some studies present an area that is not exempt from risks (Obach et al., 1983; Wu et al., 2020), or other types of adverse effects (Müller‐Vahl, 1985; Wu et al., 2020). This type of injuries is underdocumented, in relation to adverse effects in DS. This lack of reported complications in VS may be due to the lower use of injection in clinical settings, and it would be necessary to have studies that would allow adverse effects to be determined proportionally, in both injection sites.

Due to the frequency of serious injection injuries, experimental designs would require large sample sizes and would be difficult to carry out. The observational designs, in both injection sites, would allow us to approach the problem. However, VS is hardly used in clinical setting, which makes difficult to assess the real risks of this site. Some authors argue that more studies are required before excluding the dorsogluteal site (Brown et al., 2015; Gillespie & Toner, 2013), but the reality is that the ventrogluteal site has been excluded from clinical practice for decades without it being properly evaluated.

5.1. Limits and strengths

The control group in most of the studies was the same patient, which makes it possible to ensure that the results found are due, most likely, to the injection site used. As limitations of the review, some outcomes analysed are indirect measures of the accuracy of the injection. Bioavailability or effectiveness of the drug would have been real indicators of injection reliability. Regarding the design of the included studies, RCT is the gold standard in study design, but this systematic review includes any design which compares outcomes in VS and DS, so bias and confounding factors may not be adequately addressed in evidence produced. To counteract this effect a quality appraisal, using scales and manuals adapted for each design, was carried out. Studies with unacceptable scores were not included.

6. CONCLUSIONS

This review has identified a thinner SAT in the ventrogluteal site; however, there was no difference rate of theoretical subcutaneous injection between VS and DS. Comparing average SAT reported in studies and needle length, it was estimated in normal and overweight men patients a 21G needle‐38 mm (1.5 inch) could reach muscle, in both VS and DS. In obese patients, a 50 mm needle would be necessary. In overweight women, the needle of 38 mm does not ensure the intramuscular injection, but more studies are required to determine if the use of a 50 mm needle is safe especially in the VS.

Pain, bleeding and hematoma were considered lower in VS. Only one study reported sciatic nerve being closer to the DS than the VS. Any study compared serious injuries in both sites. Cases, case series and retrospectives studies of sciatic nerve or other serious complications were mostly focused on DS of injection. If ventrogluteal injection was used more frequently, observational studies could proportionally compare injuries in both sites. With the available evidence, we can conclude that the VS is safer and produces less adverse effects when compared to the DS.

FUNDING INFORMATION

This research was funded by Spanish Centre on Evidence‐Based Care: A Center of Excellence of the Joanna Briggs Institute, grant number SIVI File 1308/13–1.

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no conflict of interest in relation to this work.

RELEVANCE TO CLINICAL PRACTICE

Varying and fragmented information exists in research about what the most suitable injection sites are in adult. Ventrogluteal injection does not demonstrate more reliability than dorsogluteal in reach muscle tissue, but it does present fewer adverse effects: pain, bleeding and hematoma.

ACKNOWLEDGEMENTS

The authors would like to thank Spanish Centre on Evidence‐Based Care and Coordinating Center for Evidence‐Based Care of the Region of Murcia for their support, and Neda Kabiri, at the Research Center for Evidence‐based Medicine, Iranian EBM Centre, for her help in translation.

Roldán‐Chicano, M. T. , Rodríguez‐Tello, J. , Cebrián‐López, R. , Moore, J. R. , & del Mar García‐López, M. (2023). Adverse effects of dorsogluteal intramuscular injection versus ventrogluteal intramuscular injection: a systematic review and meta‐analysis. Nursing Open, 10, 5975–5988. 10.1002/nop2.1902

DATA AVAILABILITY STATEMENT

The data that supports the findings of this study are available in the supplementary material of this article.

REFERENCES

  1. Apaydin, E. (2018). Comparison of intramuscular injections applied to the ventrogluteal and dorsogluteal sites in terms of bleeding, pain and hematoma . [Master's thesis, Karadeniz Technical University, Trabzon, Turkey]. National Thesis Center. https://tez.yok.gov.tr
  2. Arslan, G. G. , & Özden, D. (2018). Creating a change in the use of ventrogluteal site for intramuscular injection. Patient Preference and Adherence, 12, 1749–1756. 10.2147/PPA.S168885 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Ayinde, O. , Hayward, R. S. , & Ross, J. D. C. (2021). The effect of intramuscular injection technique on injection associated pain; a systematic review and meta‐analysis. PLoS One, 16(5), e0250883. 10.1371/journal.pone.0250883 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Brown, J. , Gillespie, M. , & Chard, S. (2015). The dorso‐ventro debate: in search of empirical evidence. British journal of nursing (Mark Allen Publishing), 24(22), 1132–1139. 10.12968/bjon.2015.24.22.1132 [DOI] [PubMed] [Google Scholar]
  5. Boyd, A. E. , DeFord, L. L. , Mares, J. E. , Leary, C. C. , Garris, J. L. , Dagohoy, C. G. , Boving, V. G. , Brook, J. P. , Phan, A. , & Yao, J. C. (2013). Improving the success rate of gluteal intramuscular injections. Pancreas, 42(5), 878–882. 10.1097/MPA.0b013e318279d552 [DOI] [PubMed] [Google Scholar]
  6. Cassiani, S. H. d. B. , & Rangel, S. M. (1999). Local complications after intramuscular injections in adults: Literature review. Medicina, 32(4), 444–450. 10.11606/issn.2176-7262.v32i4p444-450 [DOI] [Google Scholar]
  7. Castellanos, B. E. (1977). Bibliographic review of studies relative to the different regions for the application of intramuscular injections. Revista da Escola de Enfermagem da U S P, 11(2), 85–99. 10.1590/0080-6234197701100200085 [DOI] [PubMed] [Google Scholar]
  8. Chan, V. O. , Colville, J. , Persaud, T. , Buckley, O. , Hamilton, S. , & Torreggiani, W. C. (2006). Intramuscular injections into the buttocks: are they truly intramuscular? European journal of radiology, 58(3), 480–484. 10.1016/j.ejrad.2006.01.008 [DOI] [PubMed] [Google Scholar]
  9. Choi, D. W. , Sohng, K. Y. , & Kim, B. S. (2010). Prediction of optimal gluteal intramuscular needle length by skinfold thickness measurements in Korean adults. Journal of Korean Academy of Nursing, 40(6), 844–851. 10.4040/jkan.2010.40.6.844 [DOI] [PubMed] [Google Scholar]
  10. Cochrane Collaboration . (2014). Review manager (RevMan) [computer program]. Version 5.3. The Nordic Cochrane Centre. [Google Scholar]
  11. Coskun, H. , Kilic, C. , & Senture, C. (2016). The evaluation of dorsogluteal and ventrogluteal injection sites: A cadaver study. Journal of Clinical Nursing, 25(7–8), 1112–1119. 10.1111/jocn.13171 [DOI] [PubMed] [Google Scholar]
  12. De Meneses, A. S. , & Marques, I. R. (2007). A proposal for a geometrical delimitation model for ventro‐gluteal injection. Revista Brasileira de Enfermagem, 60(5), 552–558. 10.1590/S0034-71672007000500013 [DOI] [PubMed] [Google Scholar]
  13. Elgellaie, A. , Ashcroft, E. , & Larkin, T. A. (2018). Effects of thickness of muscle and subcutaneous fat on efficacy of gluteal intramuscular injection sites. British Journal of Nursing, 27(6), 300–305. 10.12968/bjon.2018.27.6.300 [DOI] [PubMed] [Google Scholar]
  14. Gillespie, M. , & Toner, A. (2013). The safe administration of long‐acting depot antipsychotics. British Journal of Nursing, 22(8), 464–469. 10.12968/bjon.2013.22.8.464 [DOI] [PubMed] [Google Scholar]
  15. Güneş, Ü. , Kara Yılmaz, D. , Arı, S. , & Ceyhan, O. (2013). Which site is more painful in intramuscular injections? The dorsogluteal site or the ventrogluteal site? A case study from Turkey. Clinical Nursing Studies, 1(4), 74–81. 10.5430/cns.v1n4p74 [DOI] [Google Scholar]
  16. Güneş, Ü. , Zaybak, A. , & Tamse, S. (2008). Ventrogluteal bölgenin tespitinde kullanilanyöntemin güvenirliğinin incelenmesi. C.Ü. Hemşirelik Yüksekokulu Dergisi, 12(2), 1–8. [Google Scholar]
  17. Haramati, N. , Lorans, R. , Lutwin, M. , & Kaleya, R. N. (1994). Injection granulomas. Intramuscle or intrafat? Archives of Family Medicine, 3(2), 146–148. [DOI] [PubMed] [Google Scholar]
  18. Higgins, J. P. T. , & Green, S. (2011). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration Available from http://handbook.cochrane.org.
  19. Isseven, S. D. , Student, M. S. C. , & Sagkal Midilli, R. N. (2020). A comparison of the dorsogluteal and ventrogluteal sites regarding patients' levels of pain intensity and satisfaction following intramuscular injection. International Journal of Caring Sciences, 13(3), 2168–2179. [Google Scholar]
  20. Jung Kim, H. , & Hyun Park, S. (2014). Sciatic nerve injection injury. The Journal of International Medical Research, 42(4), 887–897. 10.1177/0300060514531924 [DOI] [PubMed] [Google Scholar]
  21. Kaya, F. , Özdemir, A. T. , Demirel, T. , & Çelik, İ. (2014). Nicolau syndrome due to diclofenac sodium (Voltaren®) injection: A case report. Journal of Medical Case Reports, 8, 404. 10.1186/1752-1947-8-404 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Kemaloğlu, Y. (2013). The comparison of ventrogluteal and dorsogluteal areas depending on development of pain, bleeding and hematoma in intramuscular injection . [Master's thesis, Halic University, Istanbul, Turkey]. National Thesis Center. https://tez.yok.gov.tr/UlusalTezMerkezi/tezDetay.jsp?id=NX49FlN3J9fZvWKF_iU6lg&no=PjzGpsx3uDTNjfLDLI4OfQ
  23. Kim, D. H. , Murovic, J. A. , Tiel, R. , & Kline, D. G. (2004). Management and outcomes in 353 surgically treated sciatic nerve lesions. Journal of Neurosurgery, 101(1), 8–17. 10.3171/jns.2004.101.1.0008 [DOI] [PubMed] [Google Scholar]
  24. Larkin, T. A. , Ashcroft, E. , Elgellaie, A. , & Hickey, B. A. (2017). Ventrogluteal versus dorsogluteal site selection: A cross‐sectional study of muscle and subcutaneous fat thicknesses and an algorithm incorporating demographic and anthropometric data to predict injection outcome. International journal of nursing studies, 71, 1–7. 10.1016/j.ijnurstu.2017.02.017 [DOI] [PubMed] [Google Scholar]
  25. Larkin, T. A. , Ashcroft, E. , Hickey, B. A. , & Elgellaie, A. (2018). Influence of gender, BMI and body shape on theoretical injection outcome at the ventrogluteal and dorsogluteal sites. Journal of Clinical Nursing, 27(1–2), e242–e250. 10.1111/jocn.13923 [DOI] [PubMed] [Google Scholar]
  26. Lippincott Williams & Wilkins . (2009). Intramuscular injection technique. In Nursing procedures (5ª ed.). Wolters Kluwer/Lippincott Williams & Wilkins. [Google Scholar]
  27. Masuda, S. , Yasuhara, Y. , Tanioka, T. , Atsuta, A. , Motoki, K. , Takase, K. , & Locsin, R. (2016). Comparison of gluteal muscle intramuscular injection sites of Japanese healthy subjects: Considerations for optimal insertion of injection needle length. Open Journal of Psychiatry, 6(2), 203–212. 10.4236/OJPSYCH.2016.62025 [DOI] [Google Scholar]
  28. Mishra, P. , & Stringer, M. D. (2010). Sciatic nerve injury from intramuscular injection: A persistent and global problem. International Journal of Clinical Practice, 64(11), 1573–1579. 10.1111/j.1742-1241.2009.02177.x [DOI] [PubMed] [Google Scholar]
  29. Moharreri, A. , Nasiri, H. , Jahanshahi, M. , Rahmani, H. , Abdollahi, A. , & Rabiei, M. (2007). The comparison of pain intensity and rate of bleeding in intramuscular injection in dorsogluteal and ventrogluteal area. Journal of Gorgan University of Medical Sciences, 9(3), 37–41. [Google Scholar]
  30. Moskalewicz, A. , & Oremus, M. (2020). No clear choice between Newcastle‐Ottawa scale and appraisal tool for cross‐sectional studies to assess methodological quality in cross‐sectional studies of health‐related quality of life and breast cancer. Journal of Clinical Epidemiology, 120, 94–103. 10.1016/j.jclinepi.2019.12.013 [DOI] [PubMed] [Google Scholar]
  31. Müller‐Vahl, H. (1985). Isolated complete paralysis of the tensor fasciae latae muscle. European Neurology, 24(5), 289–291. 10.1159/000115810 [DOI] [PubMed] [Google Scholar]
  32. Nakajima, Y. , Fujii, T. , Mukai, K. , Ishida, A. , Kato, M. , Takahashi, M. , Tsuda, M. , Hashiba, N. , Mori, N. , Yamanaka, A. , Ozaki, N. , & Nakatani, T. (2020). Anatomically safe sites for intramuscular injections: A cross‐sectional study on young adults and cadavers with a focus on the thigh. Human Vaccines & Immunotherapeutics, 16(1), 189–196. 10.1080/21645515.2019.1646576 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Nisbet, A. C. (2006). Intramuscular gluteal injections in the increasingly obese population: Retrospective study. BMJ, 332(7542), 637–638. 10.1136/bmj.38706.742731.47 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Obach, J. , Aragones, J. M. , & Ruano, D. (1983). The infrapiriformis foramen syndrome resulting from intragluteal injection. Journal of the Neurological Sciences, 58(1), 135–142. 10.1016/0022-510X(83)90116-8 [DOI] [PubMed] [Google Scholar]
  35. Öçal, H. (2012). Comparison of dorsogluteal and ventrogluteal regions in terms of pain, bleeding and hematoma development in intramuscular injections . [Master's thesis, Marmara University Republic of Turkey]. Proquest. https://www.proquest.com/openview/33fd319278ea8ba6db5eab14a9e90a4f/1?pq‐origsite=gscholar&cbl=2026366&diss=y
  36. Oliveira, L. F. , Junqueira, P. S. , Silva, M. R. d. , Souza, M. M. d. , Teles, S. A. , & Junqueira, A. L. N. (2015). Randomized controlled clinical trial: ventral gluteal region, alternative site for application of benzathine G benzylpenicillin. Revista Eletrônica de Enfermagem, 17(4), 1–7. 10.5216/ree.v17i4.29612 [DOI] [Google Scholar]
  37. Paez, A. (2017). Gray literature: An important resource in systematic reviews. Journal of Evidence‐Based Medicine, 10(3), 233–240. 10.1111/jebm.12266 [DOI] [PubMed] [Google Scholar]
  38. Page, M. J. , McKenzie, J. E. , Bossuyt, P. M. , Boutron, I. , Hoffmann, T. C. , Mulrow, C. D. , Shamseer, L. , Tetzlaff, J. M. , Akl, E. A. , Brennan, S. E. , Chou, R. , Glanville, J. , Grimshaw, J. M. , Hróbjartsson, A. , Lalu, M. M. , Li, T. , Loder, E. W. , Mayo‐Wilson, E. , McDonald, S. , … Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71. 10.1136/bmj.n71 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Razzouki, H. I. , Kadhim, S. J. , & Salman, A. H. (2013). The pattern and management of gluteal abscess disease at Al‐Yarmouk teaching hospital. Mustansiriya Medical Journal, 12(2), 6. [Google Scholar]
  40. Sahebkar, M. , Khosrojerdi, A. , Rad, M. , Stewart, J. J. , Rastaghi, S. , & Assarroudi, A. (2021). Evaluation of the effect of selecting gluteal injection site on the pain injection based on anthropometric indices and body shape pattern: A randomised controlled trial study. Journal of Clinical Nursing, 30(11–12), 1556–1563. 10.1111/jocn.15703 [DOI] [PubMed] [Google Scholar]
  41. Şanlialp Zeyrek, A. , Takmak, Ş. , Kurban, N. K. , & Arslan, S. (2019). Systematic review and meta‐analysis: Physical‐procedural interventions used to reduce pain during intramuscular injections in adults. Journal of Advanced Nursing, 75(12), 3346–3361. 10.1111/jan.14183 [DOI] [PubMed] [Google Scholar]
  42. Shah, D. K. , Missmer, S. A. , Correia, K. F. , & Ginsburg, E. S. (2014). Pharmacokinetics of human chorionic gonadotropin injection in obese and normal‐weight women. The Journal of clinical endocrinology and metabolism, 99(4), 1314–1321. 10.1210/jc.2013-4086 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Small, S. P. (2004). Preventing sciatic nerve injury from intramuscular injections: Literature review. Journal of Advanced Nursing, 47(3), 287–296. 10.1111/j.1365-2648.2004.03092.x [DOI] [PubMed] [Google Scholar]
  44. Soliman, E. , Ranjan, S. , Xu, T. , Gee, C. , Harker, A. , Barrera, A. , & Geddes, J. (2018). A narrative review of the success of intramuscular gluteal injections and its impact in psychiatry. Bio‐Design and Manufacturing, 1(3), 161–170. 10.1007/s42242-018-0018-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Strohfus, P. , Palma, S. , & Wallace, C. T. (2021). Dorsogluteal intramuscular injection depth needed to reach muscle tissue according to body mass index and gender: A systematic review. Journal of Clinical Nursing, 31, 2943–2958. 10.1111/jocn.16126 [DOI] [PubMed] [Google Scholar]
  46. Su, S. , & Bekmezci, E. (2020). The reasons for nurses not to use ventrogluteal region in intramuscular injection administration. Journal of Education and Research in Nursing, 17(1), 46–50. [Google Scholar]
  47. The Joanna Briggs Institute . (2020). Critical appraisal tools. Checklist for quasi‐experimental studies . https://jbi.global/critical‐appraisal‐tools
  48. Tuğrul, E. , & Khorshıd, L. (2014). Effect on pain intensity of injection sites and speed of injection associated with intramuscular penicillin. International Journal of Nursing Practice, 20(5), 468–474. 10.1111/ijn.12161 [DOI] [PubMed] [Google Scholar]
  49. Von Hochstetter, A. (1954). Uber die intraglutäale Injektion, ihre Komplikationen und deren Verhütung. Schweizerische Medizinische Wochenschrift, 84(43), 1226–1227. [PubMed] [Google Scholar]
  50. Wexburg, E. (1935). Neuritis und polyneuritis. In Bumke O. & Foerster O. (Eds.), Handbuch der neurologie (Vol. 9, p. 87). Springer‐Verlag. [Google Scholar]
  51. Wu, J. , Cai, Y. , Cao, A. , Bi, Y. , Hu, X. , & Yang, S. (2020). Recommendation of the best site based on the distribution pattern of Extramuscular and Intramusular nerves for gluteal muscle injection. International Journal of Morphology, 38(4), 975–982. 10.4067/S0717-95022020000400975 [DOI] [Google Scholar]
  52. Yalcin, E. , Kose, S. , & Akyuz, M. (2015). Comparing the distances of different intramuscular gluteal injection sites to the sciatic nerve. Journal of Novel Physiotherapy and Physical Rehabilitation, 2(1), 14–15. 10.17352/2455-5487.000019 [DOI] [Google Scholar]
  53. Yılmaz, D. K. , Dikmen, Y. , Köktürk, F. , & Dedeoğlu, Y. (2016). The effect of air‐lock technique on pain at the site of intramuscular injection. Saudi Medical Journal, 37(3), 304–308. 10.15537/smj.2016.3.13113 [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Zaybak, A. , Güneş, U. Y. , Tamsel, S. , Khorshid, L. , & Eşer, I. (2007). Does obesity prevent the needle from reaching muscle in intramuscular injections? Journal of Advanced Nursing, 58(6), 552–556. 10.1111/j.1365-2648.2007.04264.x [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that supports the findings of this study are available in the supplementary material of this article.

Articles from Nursing Open are provided here courtesy of Wiley

RESOURCES