Rib fractures are a frequent consequence of blunt chest trauma and are associated with significant morbidity and mortality, particularly in cases of flail chest or multiple displaced fractures. While conservative management remains the traditional approach, surgical stabilization of rib fractures (SSRFs) has gained increasing attention for its potential to improve outcomes. This prospective comparative cohort study, conducted between April 2018 and August 2023, compared the effectiveness of SSRF with that of nonoperative management. A total of 114 patients with respiratory compromise from unstable rib fractures were enrolled, 57 of whom underwent SSRF via custom-made titanium plates and screws (Group A) and 57 of whom received conservative treatment (Group B). Baseline demographics and associated injuries were comparable between the groups, although flail chest was more common in the surgical cohort (40.4% vs. 19.3%, p = 0.012). By discharge, patients in the SSRF group reported significantly lower pain scores (3.6 vs. 7.5, p < 0.001) and demonstrated superior pulmonary function at follow-up (FEV₁ at 3 months: 2.84 ± 0.40 L vs. 2.06 ± 0.36 L, p < 0.001). Oxygen dependence was shorter in the surgical group (2.5 ± 0.7 vs. 5.1 ± 0.8 days, p < 0.001), and fewer patients required ventilatory support (12.3% vs. 29.8%, p = 0.022). Among ventilated patients, 50% in the SSRF group were weaned within 3 days, whereas none were weaned in the conservative group (p < 0.001). The length of hospital stay was nearly halved with surgery (4.4 ± 1.5 vs. 9.4 ± 2.3 days, p < 0.001). Mortality was lower in the surgical group (5.3% vs. 15.8%), although this difference was not statistically significant (p = 0.062). Importantly, return-to-work rates at one month were markedly higher following SSRF (59.6% vs. 16.2%, p < 0.001). Compared with conservative management, SSRF offers significant benefits in terms of pain control, respiratory recovery, and functional outcomes. These findings support broader adoption of SSRF, particularly in patients with flail chest or multiple displaced rib fractures, and highlight the feasibility of custom-made implants in resource-limited settings.