Because of the increasing number of skeletally immature athletes who compete in highly demanding sports, more children than previously are sustaining anterior cruciate ligament injuries. Treatment and patient compliance with treatment recommendations are problematic. Pediatric issues include those specific to evaluation, projected growth, and surgery. Strict activity modification can protect the knee from further injury and delay surgery, sometimes until maturity. Surgical options include physeal-sparing, partial transphyseal, and complete transphyseal procedures. Surgical procedures are demanding because typical drilling and fixation techniques can affect the physis and possibly lead to growth disturbances. A wide range of growth disturbances has been reported; these must be understood to perfect surgical technique and avoid potential growth concerns. Surgical challenges, options regarding delayed surgery, and possible outcomes all need to be clearly communicated to the patient and parents.