Medium carbon steels have been widely used in the fields of tool and die manufacturing due to their outstanding hardness and wear resistance. In this study, microstructures of 50# steel strips fabricated by twin roll casting (TRC) and compact strip production (CSP) processes were analyzed to investigate the influences of solidification cooling rate, rolling reduction, and coiling temperature on composition segregation, decarburization, and pearlitic phase transformation. The results show that a partial decarburization layer with a thickness of 13.3 μm and banded C-Mn segregation were observed in the 50# steel produced by CSP, leading to the banded distributions of ferrite and pearlite in the C-Mn poor regions and C-Mn rich regions, respectively. For the steel fabricated by TRC, owing to the sub-rapid solidification cooling rate and short processing time at high temperatures, neither apparent C-Mn segregation nor decarburization was observed. In addition, the steel strip fabricated by TRC has higher pearlite volume fractions, larger pearlite nodule sizes, smaller pearlite colony sizes and interlamellar spacings due to the co-influence of larger prior austenite grain size and lower coiling temperatures. The alleviated segregation, eliminated decarburization and large volume fraction of pearlite render TRC a promising process for medium carbon steel production.