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Rib fractures are still a relevant and frequently occurring injury associated with a significant morbidity and mortality. Six percent of all hospitalized trauma patients appeared to sustain one or more fractured ribs and the absolute incidence rate of rib fractures requiring hospital admission among the Dutch population was 29 per 100,000 person-years. Furthermore, we found that the incidence rate of rib fractures in the elderly was even higher with 72 per 100,000 person-years, which illustrates the high clinical impact of rib fractures on the elderly population. Hence, given the considerable morbidity and mortality of rib fractures in these patients, it could be argued that rib fractures may impose the largest burden of disease after hip fractures in the elderly trauma patient. Furthermore, with the increasing aging population, it is to be expected that the incidence of elderly patients with fractured ribs requiring clinical care will increase. Pain associated with rib fractures can be severe and disabling. More importantly, it is well known that ineffective pain management significantly increases the likelihood of developing pulmonary complications, which is caused by several mechanisms. First, the thoracic pain associated with rib fractures may lead to hypoventilation, consequently resulting in ineffective coughing, retention of secretions, and ultimately, atelectasis. Second, rib fractures can compromise the integrity of the chest wall, which may alter the normal breathing mechanism, especially in patients suffering from a clinical flail chest. Third, the frequently encountered concomitant injuries to the lungs, such as a pulmonary contusion or hemothorax, may negatively affect the pulmonary gas exchange. As such, in order to reduce the risk of pulmonary complications, prompt evaluation and adequate pain management has traditionally been considered as the cornerstones in the treatment of rib fractures. While non-operative treatment has traditionally been the golden standard in rib fracture treatment, it comes with several challenges and as such new treatment strategies are still being explored. In the modern-day clinical practice, the use of rib fixation has rapidly increased over the last years and it is expected that this trend will continue as it has been received with great enthusiasm in many trauma centers. Although previous randomized controlled trials reported a significant positive treatment effect of surgical fixation, the available evidence mainly focused on patients suffering from a clinical flail chest, instead of all patients with multiple rib fractures, which thus limits its generalizability. Despite rib fixation showing promising results in selected patients, there is a growing debate about the exact indication and patient selection for this operation, as there is no consensus as to which patients would benefit. Besides, while important in the decision-making process, the long-term outcomes and complication risk of surgical fixation have received little attention.