As our society's interest in competitive athletics has grown, so has the participation of our youth. Unfortunately, along with this increase in participation has come a predictable increase in rate of injury. More specifically, anterior cruciate ligament injury in the skeletally immature individual is being recognized with increasing frequency and currently poses an unsolved clinical problem. Conservative management of midsubstance anterior cruciate ligament tears in the skeletally immature population has been shown to have an unfavorable prognosis related to functional knee instability, subsequent meniscal tears, and the development of early degenerative arthritis. Despite poor outcomes following conservative treatment, many orthopaedic surgeons have been reluctant to perform anterior cruciate ligament reconstructions in skeletally immature patients due to the potential for physeal injury and resultant growth disturbance. Although there is growing evidence in the literature suggesting that anterior cruciate ligament reconstruction in the adolescent population may be safely performed using anatomic, transphyseal techniques, there are insufficient data to provide concrete guidelines in treatment of anterior cruciate ligament injuries in the prepubescent population. Management of these injuries, therefore, must be based on the physiologic and skeletal maturity of the child. Anterior cruciate ligament reconstruction in the skeletally immature individual still poses a clinical problem with the safest and most effective techniques still evolving.