Historically, in situ fixation has been considered the gold standard for the treatment of unstable slipped capital femoral epiphysis (SCFE). Open treatments can be considered in an attempt to improve outcome, primarily in an effort to decompress the hip or decrease residual deformity. For moderate and severe unstable slips, surgical hip dislocation followed by subcapital realignment has been proposed to address the metaphyseal prominence and prevent impingement. More recently, the natural history of mild slips after in situ pinning has also been questioned and new recommendations involving management with arthroscopic or mini open procedures have been proposed. The purpose of this manuscript is to review the current treatment options and to address the need for open treatments in unstable slipped capital femoral epiphysis.