This episode explores a large RCT evaluating operative versus non-operative management of flail chest. The trial randomized 207 patients and found that while overall ventilator-free days favored surgery by just over two days, the difference was not statistically significant. A planned subgroup analysis revealed that non-ventilated patients derived no meaningful benefit from surgery, whereas intubated patients experienced shorter ventilation duration, reduced length of stay, and lower mortality with operative fixation. The discussion traces the trial’s seven-year evolution, the shift in rib-fixation practice patterns, and the team’s ongoing work to examine long-term pulmonary, functional, and pain outcomes.