The majority of pediatric fractures of the lower extremity can and should be treated with closed reduction, immobilization, and close follow-up. However, there is an ongoing debate in the orthopaedic community regarding the exact role of surgical management in the treatment of pediatric fractures. In the past 2 decades, surgical management of certain fractures provided markedly better results than closed management. In certain cases, such as those requiring anatomic realignment of the physis or articular surface, there are clear indications for surgical management. Increasingly, however, surgical management is being used to maintain optimal alignment, to allow early motion, or to facilitate mobilization of children with a lower extremity fracture. For many types of fractures, both nonsurgical and surgical methods have yielded good results and have vocal advocates. Certain technical advances, such as the use of flexible intramedullary fixation and bioreabsorbable implants, have further increased enthusiasm for surgical management of pediatric fractures of the lower extremity.