Two hundred seven patients with acute, unstable flail chest injuries were randomized to receive operative treatment (n=108) or nonoperative treatment (n=99). The primary outcome of interest was in-hospital opioid requirements, measured as daily morphine milligram equivalents (MME). Secondary outcomes included generalized pain, chest wall pain, chest tightness, shortness of breath, and SF-36 Health Outcome Scores. Outcomes were assessed at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months post-injury. Overall, the results revealed no significant differences in opioid use between groups at any time point, nor were there differences in pain scores, respiratory symptoms, or health-related quality-of-life measures throughout the one-year follow-up. These findings suggest that operative treatment does not provide additional pain relief or reduce opioid consumption in patients with flail chest injuries.