We read with interest the article by Lim et al. 1 The authors concluded that manipulation is not recommended in patients with slipped capital femoral epiphysis, because of a higher risk of avascular necrosis. However, no significant differences in outcome or complication rates were shown in their study for those treated with fixation alone or manipulation with fixation. Patients with acute unstable slips undergoing manipulation and fixation within 24 hours have been reported to have better, 2 comparable, 3 or worse 4 results than those undergoing fixation alone or delayed fixation. More randomised controlled trials are needed to answer this question.

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increased air pressure, but did seem puzzled at the strange sensation. It appeared t,hat only when the seal held its breath was there any heart slowing, again indicating that the bradycardia is linked with interruption of regular respiration.

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