Forty-seven patients with acute traumatic elbow fracture–dislocations were randomized to receive intraoperative TXA (1 g before incision and 1 g at closure; n=23) or no TXA (n=24). The primary outcome of interest was heterotopic ossification (HO) occurrence on serial radiographs. Secondary outcomes included clinically relevant HO (Hastings & Graham grades 2–3), reoperation for symptomatic HO, time to HO reoperation, HO location, and range-of-motion changes. Outcomes were assessed at 2 and 6 weeks, 3 months, and ≥6 months (mean follow-up ≈13 months). Overall, the results of the study revealed a higher—but statistically non-significant—rate of HO with TXA (43.5%) versus control (16.7%). Two reoperations for symptomatic HO occurred only in the TXA arm (20% of HO cases in TXA; none in controls; mean 18.9 months to revision). These findings suggest TXA may increase HO risk after elbow fracture–dislocation surgery, but larger trials are needed to confirm or refute this signal.