Recent reports have suggested an increase in the number of anterior cruciate ligament (ACL) injuries in children, although their true incidence is unknown. The prognosis of the ACL-deficient knee in young active individuals is poor because of secondary meniscal tears, persistent instability and early-onset osteoarthritis. The aim of surgical reconstruction is to provide stability while avoiding physeal injury. Techniques of reconstruction include transphyseal, extraphyseal or partial physeal sparing procedures. In this paper we review the management of ACL tears in skeletally immature patients. . Cite this article: Bone Joint J 2013;95-B:1562–9