The incidence of anterior cruciate ligament (ACL) injury continues to increase in the skeletally immature population. These injuries were historically treated with nonsurgical measures in this age group due to concerns for iatrogenic damage to the physis during ACL reconstruction. However, delayed surgery often led to recurrent instability, meniscal tears, and chondral damage. With the development of newer and safer surgical techniques with satisfactory outcomes, ACL reconstruction has become much more common in this age group. The patient's skeletal age is often used to determine remaining growth, which helps to decide the surgical technique chosen. These techniques include physeal sparing, partial transphyseal, and transphyseal surgical options, using soft-tissue autografts. Each technique has been shown to have favorable patient-reported outcomes, but no technique is without the risk of complications. This article will review the management of skeletally immature ACL injuries, including relevant anatomy, risk factors for injury, assessment of skeletal age, and different treatment options and outcomes.