Rib fractures in the elderly population pose a significant risk for morbidity and mortality when compared with younger patients, who, in general, suffer little morbidity. The morbidities include inadequate pain management, need for intubation, prolonged ventilatory support, and the development of pneumonia. Bulger et al. investigated the impact of rib fractures after blunt chest trauma in the elderly.36 This study showed a linear relationship between age, number of rib fractures, complications, and mortality. In a similar study, Holcomb et al. retrospectively evaluated 171 patients. These authors demonstrated an increase in negative outcomes based on increasing age and number of rib fractures. By grouping ages and number of rib fractures their data revealed that patients with more than four rib fractures who are older than 45 years exhibit increased morbidity (ICU length of stay [LOS], total LOS, ventilator days, and pulmonary complications). Given the impact of type of analgesia at reducing ventilator days and pulmonary complications, the authors attempted to determine the impact of epidural analgesia. Their data were unable to demonstrate a decreased incidence of morbidity and mortality. Given that this was only a portion of their entire population, it is possible that their results suffer from a type II statistical error. Analgesia is an important aspect of the care of the elderly trauma patient with rib fractures. The Eastern Association for the Surgery of Trauma has a Practice Management Guideline on chest trauma analgesia management.37 Readers are encouraged to refer to this document on evidence-based guidelines for analgesia. In an evaluation of data from the NTDB of the American College of Surgeons Committee on Trauma, Flagel et al. reviewed a large patient population.38 These investigators showed that the overall mortality rate for patients with rib fractures was 10%. This rate increased for each additional rib fracture independent of age. There was a similar trend of increasing pulmonary complication with additional rib fractures. The incidence of pneumonia in patients with up to five rib fractures was between 3% and 5.2%. This increased to 6.8–8.4% for patients with six or more rib fractures. These authors were unable to demonstrate that age is a risk factor for mortality in patients with rib fractures. Most recent data from a multicenter study of 1,621 patients were published by the Research Consortium of New England Centers for Trauma.39 These investigators evaluated patients over the age of 50 years with nearly isolated rib fractures. Thirty-five percent of the patients were admitted to the ICU with an average ICU LOS of 16.5 days and a total hospital LOS of 27.5 days. Intubation was required in 12% of patients and 4.3% went on to require tracheostomy. Univariate analysis of the data revealed risk factors for mortality were preexisting coronary artery disease or CHF, increasing age, ISS, number of ribs fractured, and increasing AIS for associated body regions. On multivariate analysis the strongest predictors of mortality were admission to a high-volume trauma center, preexisting CHF, intubation, and increasing age. Patient-controlled analgesia showed a trend toward improving survival but was not statistically significant. The only therapeutic maneuver that proved to be protective of survival was tracheostomy. Identification of the elderly patient with rib fractures and early recognition of respiratory failure with aggressive supportive maneuvers will potentially reduce morbidity and mortality of this lethal injury in the older patient.