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Low intensity pulsed ultrasonography for fractures: systematic review of randomised controlled trials

BMJ 2009; 338 doi: (Published 27 February 2009) Cite this as: BMJ 2009;338:b351
  1. Jason W Busse, scientist1, assistant professor2,
  2. Jagdeep Kaur, student2,
  3. Brent Mollon, student3,
  4. Mohit Bhandari, associate professor2,
  5. Paul Tornetta third, professor4,
  6. Holger J Schünemann, professor5,
  7. Gordon H Guyatt, professor2
  1. 1Institute for Work and Health, Toronto, Canada
  2. 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON
  3. 3Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON
  4. 4Boston University School of Medicine, MA, USA
  5. 5Unit of Clinical Research Development and INFORMAtion Translation/CLARITY Research Team, Department of Epidemiology, Italian National Cancer Institute Regina Elena, Rome, Italy
  1. Correspondence to: J W Busse, Institute for Work and Health, 481 University Avenue, Toronto, ON, Canada M5G 2E9 jbusse{at}
  • Accepted 30 October 2008


Objective To determine the efficacy of low intensity pulsed ultrasonography for healing of fractures.

Design Systematic review of randomised controlled trials.

Data sources Electronic literature search without language restrictions of CINAHL, Embase, Medline, HealthSTAR, and the Cochrane Central Registry of Controlled Trials, from inception of the database to 10 September 2008.

Review methods Eligible studies were randomised controlled trials that enrolled patients with any kind of fracture and randomly assigned them to low intensity pulsed ultrasonography or to a control group. Two reviewers independently agreed on eligibility; three reviewers independently assessed methodological quality and extracted outcome data. All outcomes were included and meta-analyses done when possible.

Results 13 randomised trials, of which five assessed outcomes of importance to patients, were included. Moderate quality evidence from one trial found no effect of low intensity pulsed ultrasonography on functional recovery from conservatively managed fresh clavicle fractures; whereas low quality evidence from three trials suggests benefit in non-operatively managed fresh fractures (faster radiographic healing time mean 36.9%, 95% confidence interval 25.6% to 46.0%). A single trial provided moderate quality evidence suggesting no effect of low intensity pulsed ultrasonography on return to function among non-operatively treated stress fractures. Three trials provided very low quality evidence for accelerated functional improvement after distraction osteogenesis. One trial provided low quality evidence for a benefit of low intensity pulsed ultrasonography in accelerating healing of established non-unions managed with bone graft. Four trials provided low quality evidence for acceleration of healing of operatively managed fresh fractures.

Conclusion Evidence for the effect of low intensity pulsed ultrasonography on healing of fractures is moderate to very low in quality and provides conflicting results. Although overall results are promising, establishing the role of low intensity pulsed ultrasonography in the management of fractures requires large, blinded trials, directly addressing patient important outcomes such as return to function.


  • We thank Wolfram Bosenberg for translating web reference 3. JWB is funded by a new investigator award from the Canadian Institutes of Health Research and Canadian Chiropractic Research Foundation. MB is supported in part by a Canada research chair, McMaster University. HJS is funded by a European Commission: the human factor, mobility and Marie Curie Actions, scientist reintegration grant (IGR 42192).

  • Contributors: JWB, MB, and GHG were involved in the study design and concept. JWB, JK, and BM collected the data. JWB and GHG did the analysis. All authors critically revised the manuscript and approved the final version. JWB is the guarantor.

  • Funding: None.

  • Competing interests: JWB, MB, and GHG are currently involved in a multicentre, randomised controlled trial that has received partial funding from Smith and Nephew, the company that manufactures Exogen. GHG and HJS are members of the GRADE working group.

  • Ethical approval: Not required.

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