OBJECTIVE To compare the clinical and radiographic outcomes of intramedullary nail (IMN) fixation of metacarpal fractures with those of plate-screw (PS) fixation. METHODS Between 2004 and 2006, we treated 52 consecutive closed, displaced, extra-articular metacarpal fractures operatively using 1 of 2 fixation methods: IMN or PS. Patient characteristics, mechanism of injury, pattern of fracture, and preoperative radiographic parameters were similar in both groups. The outcome measures were collected and analyzed:total active motion of the digit and Disabilities of the Arm, Shoulder, and Hand score and radiographic parameters. RESULTS Thirty-eight patients received IMN fixation and 14 patients received PS fixation. Mean follow-up time was 18 weeks in the IMN group and 19 weeks in the PS group. The mean and median total active motion were 237 degrees and 250 degrees for the IMN group, 228 degrees and 248 degrees for the PS group, with no statistically significant difference between the groups. The mean Disabilities of the Arm, Shoulder, and Hand score was 9.47 in the IMN group and 8.07 in the PS group. The association between hardware type and fracture location (middle or distal third of metacarpal) was not statistically significant. Time to radiographic healing also did not reach statistical significance between groups. Operative time was significantly shorter with use of the metacarpal nail. Five patients in the IMN group displayed loss of reduction; no failure was observed in the PS group. CONCLUSIONS There were no significant differences in the clinical outcomes using either technique. Although operative time was shorter in the IMN group than in the PS group, the incidences of loss of reduction, penetration to the metacarpal-phalangeal joint, and secondary surgeries for hardware removal in the operating room were much higher in the IMN group. METHODS Therapeutic III.