Vaccine administration: Preventing serious shoulder injuries

Abstract

Erroneous administration of intramuscular vaccines, particularly above the deltoid muscle, can result in serious shoulder injuries and diminished vaccine efficacy.1 With few studies published addressing injection technique before 2002, inconsistencies arose regarding optimal vaccine administration, thus causing variations in current practice.2 We will examine cases of serious shoulder injuries as a result of incorrect technique and provide a step-by-step guide to the proper administration of intramuscular injections. In 2006, Bodor and Montalvo3 reported two cases of vaccine-related shoulder dysfunction. One patient received the 23-valent pneumococcal vaccine and the other an influenza vaccine. Both patients reported receiving injections high into the deltoid muscle, within 1 to 2 cm of the acromion. Both patients noticed severe shoulder pain and loss of range of motion within 2 days and increasing pain during a period of 2 to 5 months. One patient was diagnosed with subacromial bursitis that later progressed to adhesive capsulitis or frozen shoulder; the other was diagnosed with bicipital tendonitis, subacromial bursitis, and a mild C6 sensory radiculopathy. The authors recommended that guidelines specify avoiding vaccine injections in the upper third of the deltoid muscle. They recommended that health professionals consider vaccine-related shoulder dysfunction in patients presenting with shoulder pain and weakness following a vaccine injection. Atanasoff et al.4 reported a series of 13 cases submitted to the Vaccine Injury Compensation Program between 2006 and 2010, in which patients experienced shoulder injury related to vaccine administration. Of the cases, 62% received influenza vaccine and the remainder received tetanus–diphtheria toxoids, Td– acellular pertussis, or human papillomavirus vaccine. The proposed mechanism of injury was that vaccine, an antigenic substance, injected into synovial tissue resulted in an immune-mediated inflammatory response. Of patients, 46% stated that the vaccine was injected “too high” into the deltoid muscle. Magnetic resonance images revealed fluid collections in the deep deltoid or overlying the rotator cuff tendons, bursitis, fluid buildup within the bursa, or rotator cuff tears. About one-third of patients (31%) required surgery, with one-half of those requiring a Vaccine administration: preventing serious shoulder injuries