Skeletal manifestations of anemia in the sternum in a modern clinical sample: An initial investigation

Anemia is a globally significant condition, both today and throughout history. Studying how it affected past communities contributes to understanding its impact on vulnerable groups. However, anemia diagnosis in skeletal remains is challenging, and improving methods for diagnosis is necessary for moving forward. In current clinical practice, sternal bone marrow undergoes anemia-related changes, which could affect underlying bone structure, but the sternum has never been investigated as a skeletal marker of anemia. We used a cohort of individuals with known hematological data (N = 23) to investigate whether there are quantitative bone changes in the sternum of individuals clinically diagnosed with anemia. Sternal bone features were measured using CT imaging to calculate a ratio of the relative cortical bone to trabecular space sample. The sample was separated into non-anemic and anemic cohorts based on World Health Organization diagnostic parameters. We found significant differences in ratios between those with and without anemia, suggesting that sternal bone ratio measurements could be used as a diagnostic parameter. In individuals without clinically-diagnosed anemia, ratios never exceeded 3.6 in the manubrium and 2.3 in the sternal body. We repeated these ratio measurements using micro-CT analysis on a sample of archaeological sternums and found that the ratio diagnostic parameter could also be used in this sample to identify those who could have experienced anemia. These results demonstrate the utility of quantitative methods for diagnosing anemia in skeletal remains and suggest that sternal ratio measurements can be used as part of anemia diagnosis in past contexts.