Flail chest represents a severe injury with mortality historically reported at up to 30 per cent. Although management has changed dramatically over the past several decades, there is a paucity of large recent series. With Institutional Review Board approval, a retrospective review of all patients with flail chest admitted from January 2001 through May 2010 was undertaken. Patient demographics, outcomes, and cause of death were specifically analyzed with univariate and multivariate analysis. There were 164 patients at a median age of 51.4 years. Head injury and pulmonary contusion were present in 67 (40.8%) and 125 (77%), respectively. Pneumonia developed in 72 (43.9%). There were 41 deaths (25%), for which flail chest contributed to 15 (9.1%). Of the patients with flail chest-related death, the majority (n = 10 [66.7%]) died within 48 hours of presentation. There were only five deaths (3.0%) related to flail chest after 48 hours. Multivariate analysis of ventilator dependency revealed requirement for laparotomy (P = 0.019) or tracheostomy (P < 0.0001) and pneumonia (P = 0.0002) as significant. Pneumonia was the most significant independent predictor of overall (P < 0.0001) and intensive care unit length of stay (P < 0.0001). The mortality associated with flail chest has greatly improved; however, the rate of pneumonia remains high. Further efforts at pneumonia prevention are thus warranted.