Injury Profiles: Car Crashes — Occupants

Welcome back to Mangled Mondays, where every Monday we talk about another facet of maiming, mangling, mauling, and mistreating your main characters — and all of their friends. 

Today we’ll be talking about Car Crashes and the trajectories the occupants can go: Up and Over and Down and Under. 

For the rest of the Mangled Mondays series, [click here].

Car Crash: Up-And-Over

Lethality Index


What Is It?

This is less a specific injury than it is an injury pattern.

In a frontal car crash, an unrestrained character has two directions they can go: up and over the dashboard, or down and under it.

An up-and-over pathway means that the character is launched, facefirst, toward the windshield.


The resulting chain of impacts is dangerous and very often lethal. The characters can expect significant trauma to the head, the face, the neck, the back, the shoulders, and the arms; it’s possible that they’ll suffer trauma to the pelvis as well.

The head injury tends to produce some form of traumatic brain injury, and may cause enough trauma to be instantly lethal.

In addition to deforming and crushing, the head tends to twist a little in response to the impact with the windshield, and a large part of the force is also transmitted backward into the neck. The resulting turn and compression forces can cause compression fractures of the neck anywhere between the base of the skull and the top thoracic vertebra (T1). If the fracture is high and transects the spinal cord, this is a lethal injury; if the fracture is low enough, the character may be paralyzed below midchest.

Modern automotive glass…

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…is designed not to break apart. That means that the glass will shatter into connected bits that bend as the character goes through it. As a result, as the shoulders pass through the opening, they are forced to expand the hole the head has already made; the character may suffer fractures of one or both clavicles and/or humeral heads (ball of the humerus where it connects to the shoulder) on the way through.

While broken modern auto glass doesn’t scatter, the edge of the “body hole” can be extremely sharp. As the chest and abdomen pass through, they can suffer significant scraping and lacerations, including disembowelment.

Up-and-over is an extremely lethal way of exiting a vehicle, and characters ejected from car crashes should suffer significant injuries.

It’s definitely possible for characters to get stuck half-in-half-out of the car, trapped in the windshield.


Even if the character does not break the windshield – even if they simply strike it and are thrown back by the impact, or the glass spider-cracks but does not buckle out – it’s still a devastating amount of force that’s applied to the character’s head.


It’s important, with major injuries like this, to understand that the character should not walk away unscathed. Instead they should suffer significant injuries, particularly brain injuries. (These can be mitigated if the vehicle has a functioning airbag, but the up-and-over pathway implies that the character is loose in the car.)


Car Crash: Down-and-Under

Lethality Index


What Is It?

The down-and-under pathway is the opposite of the up-and-over pathway. Instead of the unrestrained character being thrown upward over the dashboard, they slide down and under it, where they strike (and are injured by) the compartment wall that separates the passenger compartment from the space under the hood.

The problem is that this is not a space that’s meant to contain an entire human and, depending on how fast they’re going, the person can experience significant trauma in several places.

First, the feet and ankles can essentially be crushed by the force of the incoming human above them.

The knees are prone to striking the dashboard itself, and it’s entirely possible to dislocate the patella (kneecap) or to fracture it.

The dashboard will stop the knees, but it doesn’t stop the force of the hips coming forward. Femurs can be (and often are) broken if the rate of speed is high enough, as is the pelvis.

The lumbar spine can be affected as well.

If the feet were up on the dashboard, it’s also possible for the tibia to be shoved upward right out of the knee socket. In fact, the character may knee themselves in the face so hard they destroy their teeth. This can also cause hip dislocations.


While this injury pattern isn’t as directly lethal as an up-and-over pathway – essentially every bone from the lumbar spine down can be broken in an accident where the character takes the down-and-under path – it’s still very dangerous. Hips and femurs bleed extensively when they’re broken.

The next thing to consider is the actual warping of the car. Even relatively strong and safe cars often have some intrusion into the passenger compartment, particularly in the footwell. This is unfortunate for a character who winds up in the same space. Even characters who are restrained can suffer fractures of the foot, the ankle, or the lower leg from intrusion; characters who are being thrust into the same space at the same time may be severely injured in the same way.


Entrapment, Extrication, and Sequelae

Yet worse, sometimes the crumpling and intrusion of the car into the passenger compartment pins the character in the space underneath the dashboard. It’s wholly possible for a car crash in which the impact damages the front of the car to entrap the character, who will likely be conscious and may be dying of blood loss and internal trauma.

Extrication under these conditions can take upward of 1–2 hours. Technical rescue is likely to focus on first removing the door, then the roof of the car, in order to get to the character. Medics will attempt to stabilize the person with IV fluids and a pain reliever – likely ketamine, for its benefit of supporting blood pressure, plus its ability to be used in small doses for analgesia and high doses for sedation and intubation. Meanwhile, efforts to rip the dashboard back up to allow the character to be extricated will be ongoing, often with loud tools including the Jaws of Life and large circular saws.

When the character is finally extricated, they are likely to be removed onto a stretcher and assessed. They’ll receive more care, including blankets and, potentially, splints for their legs, and will be taken to a trauma center for treatment; in remote areas, transport will likely be by helicopter.

xoxo, Aunt Scripty


This post is an excerpt from Blood on the Page Volume One: A Writer’s Compendium of Injuries. The book details thirty-one injuries with which to maim, mangle, and maul your characters, as well as nine indispensable articles of Wound Wisdom covering everything from burn stages to suture selection.

Print and digital editions are available on [Amazon], and digital editions are available [everywhere else].

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