It is important to understand that Ottawa rules are highly sensitive but not that specific for fractures. Therefore, Ottawa guides you whether to order X-Ray or not. However, Ottawa rules do not tell you whether a fracture is present or not (high sensitivity, low specificity) (2) (5). Therefore, Ottawa rules are helpful to make sure you don't miss a fracture. Yet, Ottawa rules are not made for ruling out fractures. In conclusion, Ottawa rules deem a sensitive test, not a specific test.
Many fractures do not appear on X-Ray. Therefore, absence of fractures on X-Ray does NOT rule out clinical fractures. These fractures include but not limited to (1):
1 - Tibial plateau fx
2 - Segond fx
3 - Salter-Harris type 1
How to use Ottawa rules (3), (4):
(7) Ankle: http://reference.medscape.com/calculator/ottawa-ankle-rule
(8) Foot: http://reference.medscape.com/calculator/ottawa-foot-rule-xray
(9) Knee: http://reference.medscape.com/calculator/ottawa-knee-rule-xray
Isolated tenderness of patella (no bone tenderness of knee other than patella)
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Sources:
(1) http://www.racgp.org.au/afp/2012/april/the-ottawa-knee-rules/
(2) http://www.jwatch.org/em199910010000001/1999/10/01/ottawa-ankle-rules-miss-some-significant
(3) http://reference.medscape.com/calculator/ottawa-knee-rule-xray
(4) http://www.med.unc.edu/emergmed/education/medical-students/files/Ottawa%20rules%20for%20x-ray%20of%20k...pdf
(5) https://books.google.com/books?id=A2fXLgQ6zQEC&pg=PA99&dq=%22ottawa+rules%22&hl=en&sa=X&ved=0ahUKEwiC5-GVu8vLAhXElx4KHZdADTsQ6AEIIzAB#v=onepage&q=%22ottawa%20rules%22&f=false
(6) Image of Ankle - Ottawa rule: http://www.gpnotebook.co.uk/simplepage.cfm?ID=x20060717214620511440
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