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Rib fractures are relatively common injuries which are predominantly managed non-operatively. However, there has been an increasing amount of evidence over the past two decades supporting the role of surgical management in the presence of multiple rib fractures and flail chest. The purpose of this systematic review is to provide a comprehensive overview of the surgical management of flail chest and rib fractures along with outlining the relative indications, trends in surgical technique, and the evidence comparing operative versus non-operative treatment.