Acute repair of high radial nerve injuries is controversial. This case is of an acute repair with nerve grafts. A 9 year-old boy suffered axillary impalement injury with isolated radial nerve transection and total loss of function. 3 cm of proximal nerve was debrided. The distal end of radial nerve was found at mid-humeral level and debrided to normal fascicles. The sural nerve was harvested, divided into 4 separate 8 cm grafts, and anastomosed to the proximal and distal radial nerve stumps. 10 month follow-up revealed M5 wrist extension and M4 thumb and finger extension. Series reviewing repair of radial nerve injuries reveal 14-35% M4-M5 recovery rates. This case demonstrates the advantage of acute rather than delayed treatment of high radial nerve injuries utilizing cable grafts. The excellent recovery of function demonstrates the recovery potential of nerve injuries in pediatric patients, and efficacy of acute repair in this population.