There is relatively little evidence to guide the hand surgeon in deciding which method is best for the management of hand fractures. Sir William Arbuthnot Lane developed methods for internal fixation of fractures 120 years ago, yet when and whether to apply these techniques in the management of hand fractures presents a continued dilemma. We performed a retrospective study of 47 extra-articular metacarpal and phalangeal fractures in which we matched those fixated with K-Wires to those fixated with open reduction and internal fixation. We found that initial total active range of motion after surgery (as measured at the first occupational therapy visit within 10 days of surgery) as well as final total active range of motion (as measured at last occupational therapy appointment) was greater with open reduction and internal fixation. Also, open reduction and internal fixation resulted in less superficial infections and had decreased pain at the conclusion of occupational (hand) therapy. Finally, although open reduction and internal fixation was more expensive, it required fewer post-operative visits to the surgeon’s office. To conclude, in our hand trauma practice, open reduction and internal fixation appears to compare favourably with percutaneous techniques in terms of having better outcomes and fewer complications while requiring fewer post-operative office visits, but costs more. It remains to be established if the quality is worth the cost, historical trends in open reduction and internal fixation are elaborated. This article may be classified as a level III retrospective therapeutic and economic/decision study.