BACKGROUND Traumatic flail chest injury is a potentially life threatening condition traditionally treated with invasive mechanical ventilation to splint the chest wall. Longer-term sequelae of pain, deformity, and physical restriction are well described. This study investigated the impact of operative fixation in these patients. METHODS A prospective randomized study compared operative fixation of fractured ribs in the flail segment with current best practice mechanical ventilator management. In-hospital data, 3-month follow-up review, spirometry and CT, and 6-month quality of life (Short Form-36) questionnaire were collected. RESULTS Patients in the operative fixation group had significantly shorter ICU stay (hours) postrandomization (285 hours [range 191 to 319 hours] for the surgical group vs 359 hours [range 270 to 581 hours] for the conservative group; p = 0.03) and lesser requirement for noninvasive ventilation after extubation (3 hours [range 0 to 25 hours] in the surgical group vs 50 hours [range 17 to 102 hours] in the conservative group; p = 0.01). No differences in spirometry at 3 months or quality of life at 6 months were noted. CONCLUSIONS Operative fixation of fractured ribs reduces ventilation requirement and intensive care stay in a cohort of multitrauma patients with severe flail chest injury.