BACKGROUND: Surgical rib fixation in the general population can decrease morbidity, including length of stay and ventilator days. Elderly rib fractures convey high rates of morbidity and mortality, and it is unclear whether this population benefits from operative management. METHODS: A single-centre, retrospective study at a Level 1 Australasian trauma centre was conducted. Registry-identified patients aged ≥70 years, admitted to hospital with blunt trauma-induced rib fractures, were included. Outcome measures included demographics, pre-morbid function, acute length of stay, intensive care unit admission, injury characteristics, management and complications. RESULTS: A total of 920 presentations were identified, with 295 meeting the inclusion criteria. Falls accounted for majority (n = 148/295, 50.2%), with a median Injury Severity Score of 10 (inter-quartile range [IQR] 10-14). Severe chest trauma occurred overall in 80% (n = 243/294) and all operative patients (n = 15/15). Conservative management was used in 95% (n = 280/295). Patient-controlled analgesia was common (n = 177/295, 60.0%) and regional techniques increased in the surgical approach (n = 12/15, 80.0%) compared with conservative approach (n = 71/280, 25.4%). Despite longer acute length of stay (12 days, IQR 9-15), operative management resulted in similar complications (26.7% vs. 30.4%) and no deaths. Operative intervention was significantly associated with increased number of fractures (p < 0.001), flail segment (p = 0.001) and higher chest Abbreviated Injury Score (p < 0.001); however, it was not significantly associated with age (p = 0.90), comorbidities (0.91) or anticoagulation (p = 0.51). CONCLUSION: Surgical management of rib fractures in the elderly was performed without increased complications within this centre's multimodal approach. Standard indications for rib fixation may be applicable in the elderly population, whilst comorbidities, age and anticoagulation use alone may not be adequate reasons to withhold surgical rib fixation.