Background: although the surgical treatment of flail chest has been practiced for many decades, it is still controversial. Aim: to compare between conservative treatment and surgical management intervention for flail chest. Patients and Methods: The present research is a prospective study; included 71 patients with flail chest, admitted at Al-Azhar University hospital, New Dameitta. The patients were divided into 2 groups according to the treatment they received; 33 patients in surgical fixation group and 38 in conservative management group. The basic patients' clinical characteristics, associated comorbidities, detailed intervention, laboratory investigations, and outcome were obtained. The outcome included total ventilator days, length of stay (LOS) in the intensive care unit (ICU), rate of pulmonary complications, postoperative pain, development of chronic pain, and mortality. Results: patients in surgical group had statistically significant low APACHE II score after two weeks postadmission (7.48±1.17 vs. 9.36±1.02) and higher postoperative FEV1 (1.62±0.06 vs. 1.41±0.02). Duration of mechanical ventilation was significantly shorter in surgical group (5.25±1.76 vs. 11.81±2.57 days). Total duration of ICU stay was significantly shorter in surgical group (6.12±1.55 vs. 13.86±2.40 days). No chest deformity was reported in surgical group compared to 34.2% in conservative group; and the respiratory complications were significantly lower in surgical group (30.3% vs. 73.3%). At 6 months, no significant difference between surgical and conservative groups as regard to performing usual activity (18.2% vs. 15.8%) or return to job (45.5% vs. 34.2%). However, the chronic pain was significantly low in surgical group (21.1% vs. 36.8%). No mortality was reported. Conclusion:  surgical internal fixation was found to be superior to conservative treatment for flail chest.