Introduction: Non-operative management of rib fractures can lead to significant morbidity such as chronic pain, and dyspnea. Up to 40% may also fail to return to work. Over the last decade rib fixation has made resurgence and there are emerging data supporting early fixation in patients that fail aggressive pain control even in non-flail segments. We describe our early experience with early rib fixation in a small cohort of patients with severe chest wall injury. Methods: After IRB approval, all patients who underwent surgical fixation of rib fractures were queried from the trauma database at our Level II Trauma center from 9/2014 to 9/2015. Inclusion criteria included flail segments or significant displacement with associated refractory pain and impaired oxygen exchange or ventilation. A total of n = 23 patients were analyzed for demographic data including age, gender, ISS, and chest AIS. The number of rib fractures plated, concomitant chest wall fractures, HLOS, ICU LOS, vent days and day of surgery were also analyzed. All patients underwent rib fixation through minimally invasive incisions and using DePuy Synthes MatrixRib plating system. Results: Males (n = 20) were the majority and age was 55 ± 13.5 yrs. (range 22-86). Most patients, 83% had significant chest wall destruction including concomitant scapula, sternal and clavicle fractures. The ISS was 24.7 ± 17.8 (range 9-75). Chest AIS was 3.5 ± 0.8 (range 3-6). Total LOS 10.32 ± 3.7, ICU LOS 1.26 ± 2.28, vent days 0.28 ± 0.75. Average day to fixation was 3 ± 1.21. The number of ribs repaired was 4.9 ± 2.2. None of the patients required mechanical ventilation postoperatively. At two weeks clinic follow up to 68% of patients reported no pain and were off narcotics. Two patients developed pneumonia prior to fixation and there were no deaths in this series. Conclusions: We report our preliminary experience with early rib fixation in a small cohort of patients with severe chest wall injuries. All of the patients tolerated the procedure and early outcomes were favorable, even at the extremes of age. More long-term data is needed to assess the efficacy of early rib fixation.