Perioperative allogenic blood transfusions for patients with hip fractures are associated with increased costs and complications. This prospective randomized controlled trial evaluated whether tranexamic acid (TXA) reduces blood transfusion rates and blood loss in extracapsular hip fractures, when administered at the time of hospital admission. Patients with closed intertrochanteric or subtrochanteric femur fractures undergoing intramedullary nailing (n=100) were enrolled from October 2015 to January 2019. On arrival to the hospital, patients were randomized to receive either 1 g of intravenous TXA or normal saline. Blood transfusion rates from hospital arrival to postoperative day 5 or discharge, blood loss from hospital arrival to postoperative day 3 or 4, intraoperative blood loss, length of hospital stay, 30-day mortality, and major complications were evaluated. Six patients from the TXA group and five from the placebo group were excluded because of canceled surgery, study drug infusion after incision, multiple fractures, or dropout. Patient characteristics were similar between the groups. Postoperative transfusion rates were 17.5% (7 of 40) in the TXA group and 36.7% (18 of 49) in the placebo group (relative risk, 0.48; 95% CI, 0.22-1.03; P=.046). Total blood loss was significantly less in the TXA group (mean difference, 367 mL; 95% CI, 76-657; P=.01). No significant differences were found for intraoperative blood loss, length of hospital stay, 30-day mortality, or 30-day major complications. TXA administered on hospital arrival decreased the risk of postoperative blood transfusion and mean perioperative blood loss in patients with extracapsular hip fractures. We recommend a single-dose intravenous administration of TXA at the time of hospital admission for patients with extracapsular hip fractures. [Orthopedics. 2023;46(5):e303-e309.].