The increasing incidence of anterior cruciate ligament injuries in skeletally immature children demands careful attention by orthopedic surgeons. Assessing skeletal age is essential to selecting the appropriate reconstruction technique. Males with a bone age of 15 years or older and females of 13 years and older are ideal candidates for a transphyseal anterior cruciate ligament reconstruction because there is minimal risk of growth disturbance. Children with substantial growth remaining (skeletal age males ≤12 years and females ≤10 years) seem to be at risk for more significant growth disturbance, so we generally recommend physeal-sparing techniques for these younger patients.