OBJECTIVE To systematically review the literature on the performance of ultrasound in diagnosing radiographically occult scaphoid fracture. METHODS A systematic search was performed in the MEDLINE and Embase databases. Original studies investigating the performance of ultrasound in diagnosing radiographically occult scaphoid fracture in more than 10 patients were eligible for inclusion. Studies that included both radiographically apparent and occult scaphoid fractures (at initial radiography) were only included if independent data on radiographically occult fractures were reported. Methodological quality of the studies included was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Accuracy data were extracted. Sensitivity and specificity were pooled with a bivariate random-effects model. RESULTS The inclusion criteria were met by 7 studies; total sample size comprised 314 patients. All studies, except 1, included cortical disruption of the scaphoid in their diagnostic criteria. The sensitivity and specificity of ultrasound in diagnosing radiographically occult scaphoid fracture ranged from 77.8% to 100% and from 71.4% to 100% respectively, with pooled estimates of 85.6% (95% CI: 73.9%, 92.6%) and 83.3% % (95% CI: 72.0%, 90.6%) respectively. Exclusion of two studies with a high risk of bias in any QUADAS-2 domain did not affect the pooled results. CONCLUSIONS Ultrasound can diagnose radiographically occult scaphoid fracture with a fairly high degree of accuracy. Because of its relatively low costs and fairly high sensitivity, ultrasound seems more cost-effective than empiric cast immobilization and may be used when CT and MRI are not readily available.