This study determined the influence of trabecular bone microstructure and material properties on QUS parameters using numerical simulations coupled with high‐resolution synchrotron radiation μCT. Introduction: Finite‐difference time domain (FDTD) simulations coupled to 3D microstructural models of trabecular bone reconstructed from synchrotron radiation microtomography (SR‐μCT) were used herein to compare and quantify the effects of bone volume fraction, microstructure, and material properties on QUS parameters. Materials and Methods: 3D SR‐μCT datasets of 30 trabecular human femoral bone specimens were used to create binary digital 3D models. We studied the sensitivity of quantitative ultrasound (QUS) to bone volume fraction by examining QUS parameters at different stages of trabecular thinning or thickening using an iterative dedicated algorithm. The sensitivity to bone material properties was also assessed by analyzing different scenarios in which density and stiffness could be varied independently. The effect of microstructure was qualitatively assessed by producing virtual bone specimens of identical bone volume fraction. Simulations of ultrasonic wave propagation through the trabecular bone volumes were performed using the FDTD simulation software SimSonic developed by our group. For each structure, both broadband ultrasonic attenuation (BUA) and speed of sound (SOS) were computed. Results: BUA and SOS showed a strong correlation with BV/TV (r2 = 0.94, p < 10−4) and varied quasi‐linearly with BV/TV at an approximate rate of 2 dB/cm.MHz and 11 m/s per percent increase of BV/TV, respectively. Bone alterations caused by variation in BV/TV between 5% and 25% had a greater impact on QUS variables (variation of BUA: 40 dB/cm.MHz; variation of SOS: 200 m/s) than variations caused by alterations of material properties realized either by a 30% change of density or 40% change of stiffness (BUA: 1.7 dB/cm.MHz; SOS: 43 m/s) or than diversity in microarchitecture (BUA:7.8 dB/cm.MHz; SOS: 36 m/s). Moreover, the sensitivity of BUA and SOS to changes in BMD by a given amount realized by a pure change in bone mass (or BV/TV) was found to be predominant over a pure change of mineralization, except for low BV/TV values, where both effects are comparable. Conclusions: Trabecular bone microstructure (i.e., trabecular thickness) and material properties were changed to quantify the impact of specific determinants on QUS variables. In this sample of unselected autopsies, specimen variability in bone volume seemed to have a somewhat larger impact on QUS variables than the variability of the other determinants assessed. Whether this is also the case for osteoporotic patients remains to be studied.